UNIVERSITY  OF  CALIFORNIA 
AT   LOS  ANGELES 


\     ^': 


A 

Clinical  Treatise 


ON  THE 


DISEASES 


OF  THE 


NERYOUS    SYSTEM 

By  M.  ROSENTHAL 
Professor  of  Diseases  of  the  Nervous  System  at  Vienna 


WITH  A  PREFA CE  BY  PR OFESSOR    CHARCO T 


TbansIiAted  fbom  the  Authob's  Bbvised  and  Enlarged  Edition 


BY 

L.  PUTZEL,  M.D. 

Visiting  Physician  for  Nervous  Diseases,  RandaWs  Island  Hospital.     Physician  to  the 

Class  for  Nervom  Diseases,  Bellevue  Hospital  Out-Door  Department, 

and  Pathologist  to  the  Lunatic  Asylum,  B.  I. 


Volume  II. 


NEW  toek: 

WILLIAM     WOOD      &     COMPANY 

27  Gbeat  Jones  Street 

,1879  


Copyright  bi 

WILLIAM    WOOD     &    COMPANY. 

1079. 


Trow's 

Printing  and  Bookbinding  Co., 

305-213  Bast  12t k  St., 


^^ 


VV'L 

\oo 


^.. 


CONTENTS. 


DISEASES  OF  THE  ANTERIOR  PORTION   OF  THE   CORD. 
P^^  (aijteriok  scleroses.) 


Jo  CHAPTER  XXIV. 

^  PAGE 

e^      A.  Infantile  Spinal  Paralysis 3 

'-'      B.  Acute  Spinal  Paralysis  in  the  Adult 9 

-=c  CHAPTER  XXV. 

Progressive  Muscular  Atrophy 11 

CHAPTER  XXVI. 

Neuroses  of  the  Spinal  Cord  (Spinal  Irritation,  Neurasthenia) 23 

a.  Hyperaesthetic  Form  of  Sinnal  Irritation 23 

Z».  Depressed  Form  of  Spinal  Irritation  (Neurasthenia) 26 


C  L  A  S  S      I V. 

'.    HYSTERIA  AND  ITS  CONCOMITANT  NERVOUS  DISORDERS. 

CHAPTER  XXVII. 
^   Hysteria 29 


C5 

CLASS      V. 

SPASMODIC   CEREBRAL  AND   SPINAL  NEUROSES. 

CHAPTER  XXVIII. 
Catalepsy 55 

CHAPTER  XXIX. 
Epilepsy 63 

CHAPTER  XXX. 

Eclampsia  (Acute  Epilepsy) '^^ 

A.  Eclampsia  of  Pregnant  and  Puerperal  "Women 79 

B.  Eclampsia  of  Children 84 

C.  Toxic  Eclampsia ^6 

242095 


IV  CONTENTS. 


CHAPTER  XXXI. 

PA6B 

Tetanus 89 

CHAPTER  XXXn. 
Hydrophobia 100 


CLASS    VI. 

NEUROSES  ASSOCIATED  WITH  TREMOR  AND  DISORDERS 
OF  CO-ORDINATION. 

CHAPTER  XXXIII. 
Tremor  and  Paralysis  Agitans 107 

a.  Tremor 107 

b.  Paralysis  Agitans 109 

CHAPTER  XXXIV. 
Chorea  and  its  Different  Forms 113 

A.  Chorea  Magna 113 

B.  Chorea  Minor 117 

CHAPTER  XXXV. 
Writer's  Cramp  (Spasm  of  the  Hand  with  luco-ordination) 126 

CHAPTER  XXXVI. 
Stuttering 131 


CLASS    VII. 

TOXIC  NEUROSES.— POST-FEBRILE  NERVOUS  DISORDERS.— 
ANEMIC  AND   REFLEX   PARALYSIS. 

CHAPTER  XXXVII. 

Toxic  Neuroses 137 

Saturnine  Nervous  Affections 137 

CHAPTER  XXXVIII. 
Nervous  Affections  due  to  Febrile  Diseases 145 

CHAPTER  XXXIX. 
Anaemic  and  Reflex  Paralysis 151 

A.  Ansemic  and  IschaBmic  Paralysis 151 

B.  Reflex  Paralysis 152 


CONTENTS.  V 

CLASS    VIII. 

NEUROSES  OF  THE   SEXUAL  ORGANS. 

CHAPTER  XL. 

PAGE 

Neuroses  of  the  Sexual  Organs 155 

A.  Seminal  Losses 155 

B.  Impotence 157 

C.  Aspermatism 159 


CLASS    IX. 

DISEASES   OF   THE   PERIPHERAL   NERVOUS   SYSTEM. 

General  Characteristics  of  Peripheral  Paralysis 161 

CHAPTER  XLI. 
Rheumatic  Lesions  of  the  Nerves 16«^ 

CHAPTER  XLII. 
Traumatic  Lesions  of  the  Nerves 168 

CHAPTER   XLIII. 
Diseases  of  the  Cranial  and  Spinal  Nerves  (Diseases  of  the  Spinal  Nerves  in  gen- 
eral)    176 

«.  Atrophy  of  the  Nerves 176 

b.  Neoplasms  of  the  Nerves  and  Neuromata 177 

c.  Inflammation  of  the  Nerves  (Neuritis) 178 

d.  Neuralgias 180 

I.— DISEASES  OF  TEE  CBANIAL  NEBVES. 

CHAPTER  XLIV. 

A.  Disorders  of  the  Nerves  of  Special  Sense 187 

a.  Diseases  of  the  Olfactory  Nerve 187 

b.  Diseases  of  the  Optic  Nerve 188 

c.  Neuroses  of  the  Acoustic  Nerve 189 

d.  Neuroses  of  the  Gustatory  Nerves 191 

CHAPTER   XLV. 

B.  Diseases  of  the  Motor  Cranial  Nerves  (Ocular,  Facial,  and  Hypoglossal  Nerves).  194 

a.  Diseases  of  the  Ocular  Muscles 194 

b.  Diseases  of  the  Facial  Nerve 197 

1.  Spasms  in  the  Muscles  of  the  Face 197 

2.  Paralysis  of  the  Muscles  of  the  Face 198 

c.  Diseases  of  the  Hypoglossal  Nerve 206 


VI  CONTENTS. 

CHAPTER  XLVI. 

PAoa 
C.  Diseases  of  the  Mixed  Cranial  Nerves  (Trigeminus,  Pneumogastric,  and  Spinal 

Accessory) 207 

a.  Disease  of  the  Trigeminal  Nerve 207 

1.  Neuralgia  of  the  Trigeminus 207 

2.  Spasms  of  the  Trigeminus 213 

3.  Paralysis  of  the  Trigeminus 213 

Ö.  Disease  of  the  Pneumogastric 216 

C.   Diseases  of  the  Spinal  Accessory „ 221 

11.— DISEASES  OF  THE  SPINAL  NERVES. 

CHAPTER  XLVII. 

A.  Nervous  Disorders  in  the  branches  of  the  Cervical  and  Brachial  Plexuses 224 

1.  Cervico- occipital  Neuralgia 224 

2.  Nervous  Disorders  in  the  Distribution  of  the  Phrenic 225 

3.  Cervico  brachial  Neuralgia 227 

4.  Spasms  and  Paralysis  of  the  Muscles  of  the  Arms  and  Trunk 229 

CHAPTER  XLVJII. 

B.  Nervous  Disorders  in  the  Branches  furnished  by  the  Dorsal  Cord  and  Lumbar 

Plexus 235 

1.  Dorso -intercostal  Neuralgia 235 

2.  Lumbo-abdominal  Neuralgia 237 

CHAPTER  XLIX. 

C.  Nervous  Disorders  in  the  Branches  of  the  Sacro-Coccygeal  Plexus 240 

a.  Sciatic  Neuralgia 240 

b.  Spasms  and  Paralysis  of  the  Lower  Limbs 245 

c.  Coccygodynia 249 

Neuralgias  of  the  Joints  (Arlicular  Neuroses) 250 


CLASS   X. 
VASO-MOTOR  AND   TROPHIC  NEUROSES. 

CHAPTER   L. 

Vaso-Motor  and  Trophic  Disorders 253 

1.  Migraine  (Hemicrania) -. 254 

2.  Unilateral  Atrophy  of  the  Face  (Facial  Hemiatrophy) 256 

3.  Basedow's  Disease , 257 

4.  Traumatic  and  Rheumatic  Nervous  Disorders  of  the  Sympathetic  System.  201 

5.  Vaso-motor  Angiua  Pectoris 204 

6.  Neuroses  of  the  Abdominal  Sympathetic '• 265 

7.  Addison's  Disease 268 

8.  Muscular  Pseudo-hypertrophy 270 

9.  Trophic  Affections  of  the  Skin 273 

10.  Trophic  Affections  of  the  Bones  and  Joints 275 


CLINICAL    TREATISE 


OK 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


DISEASES  OF  THE  ANTERIOR  PORTION  OF  THE  CORD. 

(anterior  scleroses.) 

The  morbid  processes  occurring  in.  the  cortical  cells  of  the  brain  in 
general  progressive  paralysis  may  also  develop  in  the  cord  under  the  in- 
fluence of  various  acute  or  chronic  inflammatory  affections.  Degeneration 
and  pigmentary  atrophy  occur  in  the  multipolar  nerve-cells  of  the  anterior 
horns  and  in  the  fibres  vphich  unite  these  cells  with  the  intra-medullary 
portion  of  the  anterior  roots  and  with  the  antero-lateral  columns.  From 
careful  study  of  the  affections  of  the  anterior  spinal  nerve-roots  we  have 
become  better  acquainted  with  the  influence  of  these  delicate  and  impor- 
tant parts  upon  the  motor  and  trophic  functions,  and  a  whole  series  of 
morbid  types  have  been  discovered  which  may  be  combined  with  various 
bulbar  or  spinal  paralyses. 

The  anatomical  data  have  so  much  the  more  importance  with  regard 
to  the  theory  and  clinical  knowledge  of  the  diseases  in  question,  because 
nature  herself,  by  isolating  the  lesions  in  certain  nerve-cells,  in  certain 
groups  of  cells,  or  in  certain  bundles  of  the  white  substance,  has  furnished 
us  with  a  positive  and  precise  solution  of  all  the  problems  which  could  be 
determined  by  experimentation.  The  most  skilful  and  practised  experi- 
menter covild  never  obtain  equally  positive  results. 

In  the  following  section  we  shall  first  examine  the  rapid  inflammatory 
processes  occurring  in  the  anterior  horns  (myelitis  antica  acuta)  as  they 
are  found  in  acute  spinal  infantile  paralysis  and  in  that  of  adults;  then, 
the  chronic  inflammatory  processes  in  the  anterior  gray  columns  (myelitis 
antica  chronica),  which  constitute  the  fundamental  lesion  of  progressive 
muscular  atrophy  and  its  different  forms. 
Vol.  il.— 1 


CLINICAL    TREATISE    ON 


CHAPTER  XXIV. 

A. — Infantile  Spinal  Paralysis. 

Pathological  Anatomy. 

Thanks  to  the  attention  which  has  lately  been  paid  to  lesions  of  the 
anterior  gray  columns  of  the  cord,  the  nature  of  infantile  spinal  paraly- 
sis has  become  known  for  a  short  period.  Cornil  (Comptes  rendus  de  la 
Soc.  de  Biologie,  1864)  relates  the  history  of  a  woman,  forty-nine  years  of 
age,  who  had  suffered  from  paralysis  of  several  muscles  of  the  legs  since 
the  age  of  ten  years.  The  autopsy  revealed  atrophy  of  the  anter o-lateral 
columns  and  the  presence  of  abundant  amyloid  corpuscles  in  the  anterior 
horns. 

But  Cornil  did  not  interpret  these  changes  in  their  proper  light.  Pre- 
vost  and  Vulpian  (Gaz.  Med.  de  Paris,  1866)  were  the  first  to  observe 
atrophy  and  partial  sclerosis  of  the  left  anterior  horn  and  atrophy  of  the 
anterior  roots,  with  fatty  degeneration  of  the  muscles  and  their  nerves, 
in  a  woman,  seventy-eight  years  of  age,  who  had  had  a  deformity  of  the  left 
foot  since  childhood.  In  addition,  the  traces  of  a  recent  cerebro-spinal 
meningitis  were  present  (without  notable  symptoms  during  life).  Then 
followed  Charcot  and  Joffroy  (Arch,  de  Physiol.,  1870),  Parrot  and  Joffroy 
(the  same  Archives),  and  Roger  and  Damaschino  (Gaz.  Med.  de  Paris, 
1871,  4.  Observ.),  who  observed,  in  infantile  spinal  paralysis,  atrophy  and 
deformity  of  the  anterior  horns,  increase  of  the  connective-tissue  net- 
work, fatty  degeneration  of  the  vessels,  and  atrophy  of  the  nerve  cells  and 
fibres,  with  partial  sclerosis  of  the  antero-lateral  columns  and  anterior 
roots. 

Other  observations  of  the  same  character  have  been  recently  published. 
Recklinghausen  (Jahrb.  d.  Kinderheilk.,  1871)  reported  a  case  of  atrophy 
of  the  cells  of  the  anterior  horns,  of  the  anterior  columns,  and  of  the  an- 
terior p)ortions  of  the  lateral  columns.  M.  Roth  (Virch.  Arch.,  Bd.  58, 
1873)  relates  a  case  of  destruction  of  the  right  anterior  horn  (visible 
under  a  low  magnifying  power),  with  atrophy  of  the  nerve  cells  and  fibres 
and  of  the  anterior  roots.  In  addition  there  was  2:)artial  myelitis  of  the 
posterior  horn  and  of  the  antero-lateral  column.  Finally,  I  have  also  had 
the  opportunity  of  examining  sections  of  the  cord,  after  hardening  in 
chromic  acid,  in  a  case  of  infantile  spinal  paralysis  {vide  Med.  chir.  Rund- 
schau, Feb.  Heft,  1872).  The  appearances  presented  in  these  preparations 
were  the  following  :  atrophy  and  deformity  of  the  anterior  horn  involved, 
rarefaction  of  the  nerve-cells  in  certain  places  and  amyloid  degeneration 
of  the  cells  in  others,  sclerotic  enlargement  with  final  atrophy,  frequent 
absence  of  the  nucleus,  and  complete  disappearance  of  th«  cells,  here  and 
there,  their  place  being  occupied  by  a  finely  wavy  connective  tissue.  The 
vessels  were  considerably  enlarged  and  thickened,  and  the  gray  substance 
was  very  vascular.  There  was  atrophy  with  sclerosis  of  the  antero-lateral 
column,  corresponding  to  the  lesion  of  the  anterior  horn.     Leyden  has 


DISEASES    OF    THE    NERVOUS    SYSTEM.  3 

recently  demonstrated  (Arch.  f.  Psych.,  VI.,  1876)  that  spinal  infantile 
paralysis  may  be  produced  by  various  morbid  processes  (sclerosis,  cica- 
trization, myelitis),  whose  sole  common  characteristic  consists  of  their 
acute  character  and  their  situation  in  the  anterior  gray  substance.  Ac- 
cording to  Volkmann,  the  paralyzed  micscles,  even  after  the  disease  has 
lasted  several  years,  merely  present  simple  atrophy  of  the  fibres,  "which 
have  a  finely  granular  appearance,  with  increase  of  nuclei  and  of  the  inter- 
stitial fatty  tissue.  According  to  Hayem,  proliferation  of  the  nuclei  occurs 
in  the  perimysium  and  sarcolemma,  and  this  accumulation  renders  the  mus- 
cular fibres  friable,  without  modifying  the  appearance  of  the  stria?  to  any 
appreciable  extent. 

Etiology. 

Infantile  spinal  paralysis  occurs  in  the  first  three  years  of  life,  and  usu- 
ally between  the  sixth  and  fourteenth  months.  The  children  appear  to 
enjoy  good  health  previously,  but  sometimes  have  a  delicate  constitu- 
tion, a  pale  color  and  a  very  irritable  disposition.  Nervous  disorders 
are  not  infrequently  present  in  the  parents,  especially  in  the  mother.  I 
have  seen  several  cases  in  which  the  mother  had  suffered  from  abdominal 
spasms,  and  in  which  other  children  in  the  family  had  died  of  eclampsia 
or  hydrocephalus.  The  action  of  cold  is  very  problematical,  and  external 
influences  (compression,  according  to  Kennedy)  do  not  appear  to  play  any 
part  in  the  etiology  of  the  disease  in  question.  According  to  Holmes 
Coote,  among  1,000  children  admitted  to  the  Royal  Orthopedic  Hospital, 
there  were  80  cases  of  infantile  spinal  paralysis,  or  8  in  100.  Among  192 
cases  of  paralysis  occurring  in  children,  Heine,  Jr.,  observed  158  of  spinal 
origin,  of  which  81  were  partial  paralyses.  Sex  appears  to  possess  no  ap- 
preciable influence  upon  the  frequency  of  occurrence  of  the  disease. 

Charcot  and  Joffroy  consider  the  primary  atrophy  of  the  nerve-cells  of 
the  anterior  horns  as  the  point  of  departure  of  the  disease.  This  lesion, 
together  with  secondary  atrophy  of  the  anterior  roots,  is  sometimes  the 
only  textural  change  that  can  be  discovered  with  the  microscope  upon 
transverse  sections  of  the  cord.  The  posterior  horns  and  white  columns 
of  the  cord  are  only  affected  secondarily  and  to  a  minor  degree  by  the 
final  development  of  the  morbid  process.  Other  French  observers  have 
arrived  at  the  same  conclusions.  In  opposition  to  this  view,  I  desire  to 
formulate  another  pathogenic  theory  of  this  disease,  which  appears  to  me 
to  render  the  interpretation  of  the  facts  more  simple  and  natural.  If  we 
examine  transverse  sections  of  different  regions  of  the  cord,  we  can  readi- 
ly distinguish,  in  the  anterior  horns  which  are  most  involved,  very  marked 
congestion,  with  dilatation  and  thickening  of  the  vessels.  The  capillary 
network  is  also  much  more  developed  in  the  gray  substance  than  usual. 

These  significant  changes,  and  the  abundant  production  of  small  nuclei 
around  the  vessels,  demonstrate  that  the  latter  take  an  active  part  in 
the  affection.  We  are,  therefore,  justified  in  believing  that  the  disease 
begins  with  medullary  hyperiemia  and  vascular  exudation.  The  latter 
becomes  more  intense  and  more  widely  diffused,  compromises  the  nutrition 
of  the  nerve-cells  of  the  gray  substance,  and  acts  as  the  cause  of  the 
secondary  proliferations  and  deformities.  This  inflammatory  irritation, 
produced  in  the  vascular  system  of  the  cord,  should  be  manifested  by  the 
general  symptoms  of  exudation  and  by  febrile  movement,  and,  in  fact, 
these  are  the  first  signs  which  herald  an  attack  of  infantile  paralysis. 

If  this  vascular  irritation  is,  at  first,  moderate  in  severity  and  extent, 


4  CLINICAL    TREATISE    ON 

recovery  is  possible,  provided  that  the  delicate  structure  of  the  nerve-cells 
has  not  been  compromised.  It  is  probable  that  at  least  a  portion  of  the 
temporary  paralyses,  described  by  Kennedy,  belong  to  this  category. 
Physicians  frequently  make  observations  which  tend  to  demonstrate  the 
possibility  of  the  partial  recovery  of  these  vascular  irritations  ;  we  refer 
to  the  fact  that,  after  the  acute  period  of  the  disease,  the  paralysis,  which 
often  invades  the  trunk  and  limbs,  abandons  the  upper  parts  of  the  body 
and  remains  localized  in  one  or  both  lower  limbs. 

But  if  the  vascular  irritation  is  very  severe  at  the  outset,  the  nerve- 
cells,  which  present  such  a  delicate  structure  in  the  infant,  will  become 
rapidly  impaired.  The  morbid  process  then  terminates  in  secondary  pro- 
liferation and  deformity  of  the  nerve-cells,  nerve-roots,  and  corresponding 
white  columns.  It  appears  that  these  vascular  disturbances  chiefly  in- 
volve the  gray  substance,  because,  in  the  normal  condition,  it  is  richer  in 
capillaries  than  the  white  matter,  as  has  been  demonstrated  by  injec- 
tions. As  the  small  nutrient  vessels  are  not  always  situated  on  the  same 
level  as  the  nerve-cells  which  are  affected,  it  sometimes  follows  that,  in 
the  microscopic  preparations,  we  find  manifest  vascular  changes  without 
coexisting  lesions  in  the  cells,  or,  inversely,  diseased  nerve-cells  appear 
side  by  side  with  apparently  normal  vessels.  These  facts  justify  us  in  the 
supposition  that,  in  certain  cases  of  infantile  spinal  paralysis,  the  lesions 
of  the  white  substance  may  retrograde,  while  the  gray  substance  of  the 
anterior  columns,  on  account  of  its  more  delicate  structure  and  greater 
vascularity,  undergoes  profound  changes. 


Symptomatology. 

Infantile  paralysis  was  described  as  early  as  the  last  century  by  Under- 
wood (Treatise  on  the  Diseases  of  Children,  London,  1784).  Rilliet 
erroneously  considered  it  to  be  an  idiopathic  paralysis,  and  Duchenne  de- 
scribed it  under  the  name  of  fatty  atrophic  paralysis  of  childhood.  It 
usually  begins  suddenly.  After  one  or  several  attacks  of  fever,  accom- 
panied by  general  symptoms  of  irritation  (insomnia,  convulsions,  delirium, 
cries),  but  usually  without  disturbance  of  the  intelligence,  the  parents  or 
attendants  notice,  to  their  great  surprise,  when  lifting  the  child,  that  he 
has  been  seized  with  paralysis  during  the  night.  The  acute  period  only 
continues  a  short  time,  and  is  often  entirely  unnoticed.  The  paralysis 
then  becomes  evident,  and  frequently  extends  to  the  trunk  and  limbs.  But 
it  soon  leaves  the  upper  parts  of  the  body,  and  remains  permanent  in  one 
or  two  limbs,  or  only  in  certain  groups  of  muscles.  This  circumscribed 
paralysis  usually  involves  one  of  the  upper  or  lower  limbs.  In  the  upper 
limbs  the  muscles  affected,  by  preference,  are  the  extensors  of  the  arm 
or  forearm  and  fingers;  in  the  lower  limbs  they  are  the  extensor  of  the 
thigh  (psoas),  but  much  more  frequently  the  muscles  inn.ervated  by  the 
peroneal  nerve,  or  the  triceps  muscle.  Spinal  infantile  paralysis  may  as- 
sume the  form  of  paraplegia,  and  very  rarely  of  hemiplegia  (the  latter  is 
almost  always  of  cerebral  origin).  It  may  also  affect  the  foot  and  hand 
upon  opposite  sides,  or  the  muscles  of  the  trunk  (with  secondary  lateral 
curvature  of  the  spinal  coluTnn).  In  very  rare  instances,  as  in  the  follow- 
ing observation,  the  paralysis  occurs  in  both  upper  limbs. 

A  boy,  four  years  of  age,  had  had,  two  years  previously,  after  a  short  attack  of  fever, 
general  paralysis  of  all  the  limbs,  but  which  soon  disappeared  except  in  the  two  arms. 


DISEASES    OF   THE    NERVOUS    SYSTEM.  5 

Upon  examination,  I  found  the  right  upper  limb  markedly  emaciated,  the  skin  thick- 
ened and  flaccid,  the  muscular  tissue  very  much  reduced  in  bulk.  The  shoulder  was 
atrophied,  angular,  and  was  carried  forward  with  diflBculty.  Extension  of  the  arras 
and  fingers  was  impossible,  flexion  was  performed  with  difficulty,  and  the  hand  was 
emaciated  and  fixed  in  adduction.  The  deltoid  responds  slightly  to  the  f  aradic  current, 
but  only  in  its  internal  fibres.  The  same  phenomena  are  evident  in  the  subscapularis 
and  pectoralis  major  ;  the  extensors  of  the  arm  and  fingers  scarcely  react,  the  biceps 
very  feebly.  This  also  holds  good  of  some  of  the  muscular  fibres  of  the  atrophied 
thenar  eminence.  The  galvanic  excitability  of  the  brachial  plexus,  of  the  nerves  of 
the  shoulder  and  arm,  is  very  well  preserved,  and  the  paralyzed  extensors  respond  to 
strong  currents  by  slight  contractions.  The  left  upper  limb  is  better  nourished.  It 
can  be  moved  forwards  and  backwards  with  some  effort ;  extension  of  the  arm  is  slowly 
performed,  flexion  rapidly,  and  the  fingers  are  freely  movable.  Electro-muscular  con- 
tractility is  preserved  throughout,  but  is  markedly  weakened.  I  advised  long-con- 
tinued faradization  of  the  muscles  and  galvanization  of  the  nerves.  When  I  again 
saw  the  child,  at  the  end  of  about  eight  months,  the  right  shoulder  and  hand  had 
gained  considerably  in  nutrition  and  power  of  movement,  and  the  left  side  had  almost 
completely  recovered. 

In  certain  cases  motion  is  spontaneously  re-established  within  one  or 
two  weeks,  the  electrical  contractility  of  the  affected  muscles  remaining 
but  little  or  not  at  all  affected.  In  other  cases  this  recovery  only  occurs 
after  the  lapse  of  weeks  or  months.  When  the  paralysis  remains  station- 
ary, active  movements  and  muscular  nutrition  gradually  decline,  and  the 
limb  atrophies  and  grows  cold  (after  the  disease  has  lasted  several  years, 
the  temperature  may  become  lowered  from  5°-G°  C. );  the  foot,  especially, 
becomes  livid.  The  disorders  of  muscular  nutrition  do  not  follow  the 
same  course  as  the  paralysis,  but  are,  on  the  contrary,  entirely  independ- 
ent of  them.  The  bones  (epiphyses  and  diaphyses)  of  the  atrophied  limbs 
are  also  arrested  in  their  growth,  and  the  shortening  may  amount  to  two 
or  three  centimetres.  According  to  Murray,  the  bones  are  thinned,  and 
their  nerves  and  vessels  appear  markedly  atrophied.  Sensihility  is  some- 
times exaggerated  at  the  outset,  but,  at  a  later  period,  it  again  becomes 
normal;  this  also  holds  good  with  regard  to  the  reflex  excitability.  The 
antagonism  of  the  muscles  having  disappeared,  we  notice  the  development 
of  club-foot  (genu  valgum),  of  paralytic  scoliosis  or  lordosis,  obliquity  of 
the  shoulders,  etc.,  in  consequence  of  the  weight  of  the  diseased  part,  or 
of  the  labor  imposed  by  severe  exertions  (Hueter).  The  epiphyses  atro- 
phy, and  subluxations  may  even  occur  and  permit  unnatural  passive 
movements  (Laborde).  The  paralyses  of  the  muscles  of  the  leg  and  foot 
especially  favor  the  development  of  secondary  deformities,  while  paralysis 
of  the  extensor  of  the  thigh  (I  have  reported  a  case  in  which  it  lasted 
twelve  years,  with  loss  of  electro-muscular  contractility)  only  hinders  walk- 
ing: to  a  slisfht  extent  when  the  muscles  of  the  leg  are  intact.  In  these 
cases  the  gluteal  muscles,  in  part,  execute  alternate  movements  of  exten- 
sion and  rotation  backwards,  and  then  forwards.  On  the  other  hand,  the 
thighs  and  condyles  of  the  tibia,  which  are  pressed  against  one  another 
by  the  weight  of  the  bodj^,  and  the  articular  ligaments,  furnish  to  the 
knee  a  firm  basis  of  support  during  extension.  It  is  only  in  taking  long 
walks  that  it  becomes  necessary  to  employ  an  orthopeedic  apparatus. 

'^\i.Q  far  adle  excitability  of  the  'muscles  may  become  weakened  or  may 
even  disappear  during  the  first  weeks  without  proving  an  obstacle  to 
the  return  of  motion.  As  Salomon  first  pointed  out  (Jahrb.  d.  Kinder- 
heilk.,  I.,  18G8),  and  as  Eulenburg's  observations  and  the  case  recorded 
above  also  prove,  farado-muscular  contractility  may  be  abolished  in  the 
paralyzed  muscles,  although  the  galvano-muscular  reaction  is  preserved 
for  a  long  time.     These  facts  cannot  be  doubted,  but  different  interpreta- 


6  CLINICAL    TKEATISE    ON 

tions  are  placed  upon  them  by  various  authors.  Some  have  maintained 
that  though  abolition  of  the  farado-muscular  with  preservation  of  the 
galvano-muscular  contractility  is  often  observed  in  peripheral  paralysis, 
the  same  fact  is  also  noticed  in  paralyses  of  central  origin.  Clinical 
observation  and  the  experiments  of  Erb  and  Ziemssen  have  shown  that 
the  faradic  excitability  of  the  muscles  is  very  much  enfeebled  or  abol- 
ished in  peripheral  paralyses,  but  that,  on  the  other  hand,  the  galvanic 
contractility  is  markedly  increased  at  the  onset  or  for  a  long  time  (this 
increase  is  even  apparent  with  very  weak  currents).  On  the  other  hand,  in 
central  paralyses,  in  which  the  electro-muscular  and  galvano-muscular  ex- 
citability sometimes  disappear  at  a  ver^'  early  period,  the  galvanic  con- 
tractility nevertheless  lasts  longer  than  the  faradic.  In  such  cases  the 
faradic  reaction  disappears  completely,  but  traces  of  galvanic  excitability 
may  still  be  detected  with  strong  currents.  This  occurs  in  infantile  spinal 
paralysis  and  progressive  muscular  atrophy.  If  we  carefully  examine  the 
different  muscular  territories,  we  will  find  that  the  sound  muscles  react 
well  to  both  currents,  that,  in  the  affected  muscles,  the  reaction  to  both 
currents  is  weakened,  and  that,  in  the  muscles  which  are  most  strongly 
affected,  the  faradic  contractility  has  disappeared,  but  a  weak  reaction  to 
galvanism  (with  a  strong  current)  is  still  manifested.  In  completely  atro- 
phied and  paralyzed  muscles  all  reaction  has  entirely  disappeared. 


Diagnosis  and  Prognosis. 

Infantile  spinal  paralysis,  beginning  with  symptoms  of  irritation  or 
fever,  and  involving  one  or  two  limbs  during  the  night,  is  recognized  as 
easily  as  the  old  forms,  in  which  the  diminution  of  electrical  excitability, 
and  the  atrophy  of  the  muscles  and  bones,  furnish  perfectly  distinctive 
signs.  There  are,  nevertheless,  cases  in  which  confusion  with  other  analo- 
gous conditions  is  possible,  if  we  neglect  certain  characteristic  phenomena. 
Paralyses  secondary  to  acute  cerebral  affections  of  childhood  (apoplexy, 
encephalitis,  eclampsia)  assume  the  form  of  hemiplegia  or  paraplegia,  in 
which  one  of  the  upper  or  lower  limbs  may  be  more  profoundly  involved. 
The  children  usually  complain,  for  some  days  previously,  of  violent  head- 
ache, heaviness  and  weakness  in  the  legs,  and  then  paralysis  suddenly 
appears  in  the  midst  of  general  or  partial  convulsions,  attended  with  loss 
of  consciousness.  Paralyses  of  this  kind  rarely  disappear;  in  the  majority 
of  cases  they  only  yield  in  part.  The  following  circumstances  may  be 
taken  into  consideration  in  forming  a  diagnosis  of  an  acute  cerebral  affec- 
tion :  loss  of  intelligence  and  speech;  frequently  coexisting  paralysis  of 
one-half  of  the  face;  frequent  strabismus;  dilatation  of  the  pupils;  normal 
electrical  contractility,  even  after  the  lapse  of  several  j^ears;  absence  of 
disturbances  on  the  part  of  temperature  and  muscular  nutrition  (intact 
fibres,  even  in  markedly  discolored  and  atrophied  muscles  :  Cruveilhier). 

The  paralyses  of  the  limbs,  which  occur  in  children  in  chronic  cerebral 
affections  (tumors,  chronic  hydrocephalus),  may  also  lead  to  confusion 
with  true  infantile  spinal  paralysis.  But  these  forms  of  paralysis  are 
generally  developed  slowly  and  with  fever.  They  are  not  infrequently 
accompanied  by  contractures  which  persist  for  a  long  time  in  the  same 
position  or  reappear  at  certain  intervals.  We  are  justified  in  diagnosing 
a  chronic  cerebral  disease,  from  the  following  signs:  the  appearance  of 
cerebral  symptoms  of  irritatipn  (vomiting,  convulsions,  etc.);  disorders  of 
the  intelligence  and  special  senses:  a  more  uniform  wasting  of  the  mus- 


DISEASES    OF   THE    NERVOUS    SYSTEM.  7 

cles;  electrical  excitability  scarcely  changed;  paralysis  of  a  hemiplegic 
type,  and  usually  of  slow  development. 

Progressive  muscular  atrophy  presents  great  analogy  to  infantile 
spinal  paralysis.  But  the  latter  appears  suddenly,  and  partially  retro- 
grades, while  the  former  extends  more  or  less  rapidly,  but  in  a  continuous 
manner.  Progressive  muscular  atrophy  is  exceedingly  rare  in  children. 
Duchenne  has,  however,  observed  it  in  two  children  of  the  same  family, 
aged  respectively  ten  and  twelve  years,  and  I  have  also  observed  this  affec- 
tion in  a  boy  nine  years  old  (atrophy  of  the  muscles  of  the  left  shoulder  and 
arm,  with  loss  of  voluntary  contractions  and  faradic  excitability).  The  dis- 
ease usually  appears  in  children  from  the  ages  of  five  to  seven  years,  and 
generally  begins  in  the  face,  first  attacking  the  orbicularis  oris  and  the  zy- 
gomatici  (Duchenne).  We  then  observe,  as  the  first  symptom,  a  peculiar 
immobility  of  the  lips;  they  are  separated  from  one  another;  the  lower 
lip  is  dependent,  and  the  naso-labial  fold  is  effaced.  The  patient  cannot 
purse  the  lips,  and  the  face  is  unanimated  during  laughter.  After  a  sta- 
tionary period  of  several  years,  the  upper  limbs  and  trunk  are  involved  in 
their  turn,  and,  finally,  the  lower  limbs.  The  peculiar,  progressive  course 
of  the  muscular  atrophy,  the  preservation  of  certain  muscles  in  the  imme- 
diate vicinity  of  diseased  parts,  the  atrophy  of  certain  isolated  portions 
of  the  same  muscle,  and  the  diminution  or  abolition  of  electrical  contrac- 
tility corresponding  to  the  muscular  degeneration,  are  characteristic  signs 
which  are  useful  in  doubtful  cases.  The  paralysis  of  pseudo-muscular 
hypertrojyhy  is  distinguished  from  infantile  spinal  paralysis  by  the  follow- 
ing symptoms:  the  disease  is  apyretic  throughout;  in  the  beginning, 
motor  power  is  only  weakened;  walking  or  the  vertical  position  presents  a 
staggering  character,  the  vertebral  column  is  sunken,  the  legs  are  sepa- 
rated; the  paralysis  only  extends  to  the  extremities  and  trvmk  at  a  late 
period;  the  electro-muscular  contractility  is  preserved  for  a  very  long 
time;  in  a  certain  number  of  muscles  the  paralysis  is  preceded  by  an  in- 
crease of  volume.  Finally,  we  can  recognize  the  fact,  even  during  life, 
that  simple  hyperplasia  occurs  in  the  adipose  and  interstitial  connective 
tissue. 

Delay  in  the  development  of  co-ordination  may  retard  the  poioer  of 
loalking  in  children.  We  observe,  in  these  cases,  great  weakness  of  the 
muscles  and  bones,  and  very  marked  relaxation  of  the  ligaments.  These 
children  (from  two  to  four  years  of  age)  can  move  their  legs  when  sitting 
or  lying  down;  they  can  even  carry  them  to  the  mouth  with  the  aid  of 
their  hands,  but  they  are  unable  either  to  turn  around  or  to  walk.  The 
intelligence  presents  no  appreciable  disturbances,  the  electro-muscular 
contractility  is  intact,  and  there  are  no  convulsions  or  fever.  All  these 
symptoms  are  different  from  those  observed  in  infantile  spinal  paralysis. 
The  paresis  of  co-ordination  diminishes  as  the  children  grow  stronger 
under  the  influence  of  nourishing  diet,  the  administration  of  beer  or  wine, 
and  country  air.  I  have  seen  a  case  of  this  kind  terminate  in  complete 
recovery. 

In  rachitis  we  sometimes  observe  a  condition  of  weakness  and  real 
paralysis  of  the  lower  limbs  (the  children  are  unable  to  walk,  or  even  to 
turn  about  without  assistance,  and  the  legs  are  deformed).  But  we  can 
usually  recognize  other  signs  of  rachitis  ;  the  electro-muscular  contractil- 
ity is  normal  throughout,  and  there  are  no  symptoms  of  irritation  or  fever 
(tonic  treatment,  country  air,  and  electrization  of  the  muscles  re-establish 
the  motor  power).  A  careful  examination  of  the  patient  will  prevent  us 
from  mistaking  these  cases  for  infantile  spinal  paralysis. 


8  CLINICAL    TREATISE    ON 

The  temporary  paralysis  of  children,  described  by  Kennedy  (after 
exposure  or  compression  of  the  limbs),  ojffers  all  the  characteristics  of  a 
myopathic  peripheral  paralysis.  We  find  no  change  in  the  reaction  of 
the  muscles  to  electricity,  the  nutrition  of  the  muscles  is  not  sensibly  af- 
fected, and  the  disease  terminates  in  one  or  two  weeks.  By  repeating 
the  electrical  exploration  several  times  and  by  keeping  the  patient  under 
observation  for  a  certain  period,  we  will  be  able  to  recognize  the  real  na- 
ture of  the  disease. 

The  2^rognosis  of  infantile  spinal  paralysis  depends  upon  the  intensity 
and  extent  of  the  changes  in  the  cells  of  the  anterior  horns.  If  the  pa- 
ralysis of  the  limbs  soon  becomes  circumscribed  and  partially  disappears, 
we  may  infer  that  the  central  lesions  will  follow  a  favorable  course.  The 
information  which  we  obtain  by  faradization,  concerning  the  existence  or 
absence  of  electrical  reaction  in  certain  muscles,  undoubtedly  furnishes 
us  with  some  idea  of  the  condition  of  the  muscular  tissue. 

The  hypothesis  of  Duchenne,  that  faradization  will  lead  to  the  devel- 
opment of  new  muscular  fibres  around  others  which  have  remained  intact, 
has  not  been  confirmed.  Duchenne  also  maintained  that  the  gravity  of 
the  prognosis  is  in  direct  relation  with  the  nervous  lesion  which  causes 
the  atrophy,  and  that  we  are  only  able  to  judge  of  this  lesion  by  electrical 
exploration.  We  cannot  unreservedly  admit  the  truth  of  this  statement 
in  all  cases,  as  I  have  previously  shown  by  several  examples  (Traite 
d':Electrotherapie,  2'  edit.,  pp.  196,  197). 

It  appears,  from  some  observations  reported  in  the  same  work,  that  in 
certain  cases  of  infantile  spinal  paralysis  which  have  lasted  six  to  nine 
months,  the  electrical  excitability  of  the  affected  muscles  may  be  wanting, 
although  voluntary  motion  has  returned.  Thus,  after  this  lapse  of  time, 
the  absence  of  electro-muscular  contractility,  especially  in  robust  children, 
should  not  induce  us  to  make  an  unfavorable  prognosis.  Even  in  these 
cases  we  can  produce  a  very  favorable  effect  upon  the  nutrition,  temper- 
ature, and  development  of  the  atrophied  limbs  by  persevering  in  the  elec- 
trical treatment.  (This  fact  has  been  confirmed  by  several  other  ob- 
servers.) If  electrical  excitability  and  motion  have  not  returned  within  a 
year,  all  hope  of  recovery  must  be  abandoned. 


Treatment. 

The  treatment  of  infantile  spinal  paralysis  should  be  begun,  if  possible, 
at  the  close  of  the  second  or  third  week  of  the  disease,  especially  if  no 
marked  progress  has  been  made  towards  spontaneous  recovery.  We  ob- 
tain better  results  in  this  manner  than  if  we  decide  to  begin  energetic 
treatment  only  at  the  end  of  several  months. 

Electricity,  under  the  form  of  the  galvanic  current  passing  from  the 
vertebral  column  to  the  nerves  and  muscles,  constitutes  the  best  means 
of  treatment.  We  must  continue  this  plan  for  several  months,  and 
afterwards  combine  it  with  local  faradization.  I  have  also  seen  good  ef- 
fects upon  the  nutrition  and  energy  of  the  muscles  from  hydrotherapeu- 
tics  (moist  frictions,  local  packing  of  the  extremities,  followed  by  half- 
baths  at  24.20°  C,  with  mild  irrigations  to  the  vertebral  column  during 
the  bath).  The  children  should  only  be  permitted  to  walk  when  aided  by 
an  attendant.  Appropriate  orthopgedic  treatment  may  be  useful  in  order 
to  confirm  and  correct  the  results  of  other  methods. 


DISEASES    OF    THE    NERVOUS    SYSTEM. 


B. — Acute  Spinal  Paralysis  in  the  Adult. 

In  1861,  Duchenne,  with  his  habitual  clear-sightedness,  observed  that 
a  disease  sometimes  occurs  in  adults  which  is  very  similar  to  infantile 
spinal  paralysis.  He  located  it  in  the  anterior  gray  columns  of  the  cord, 
and,  therefore,  called  it  general  anterior  spinal  paralysis. 

It  was  only  after  we  had  obtained  some  knowledge  concerning  infan- 
tile spinal  paralysis  that  we  were  in  a  condition  to  thoroughly  appreciate 
the  acute  anterior  myelitis  of  adults.  The  first  observation  of  this  kind 
was  published  by  Hallopeau  (Arch.  Genur.,  1869),  but  was  not  attended 
with  a  microscopical  examination.  The  patient  was  a  woman,  twenty 
years  of  age,  who  was  suddenly  seized,  after  confinement,  with  paralysis 
and  pains  in  all  the  limbs.  She  recovered,  little  by  little,  with  the  excep- 
tion of  the  left  leg,  the  muscles  of  which  atrophied  and  lost  their  electri- 
cal contractility.  At  a  later  period  the  left  lower  limb  also  improved, 
the  patient  was  able  to  walk  with  crutches,  but  the  electrical  reactions  re- 
mained absent.  Ten  months  later  the  woman  died  of  typhoid  fever. 
At  the  autopsy,  atrophy  and  degeneration  were  found,  especially  in  the 
posterior  muscles  of  the  left  leg  and  in  certain  muscular  nerve-fibres. 
Some  of  the  fibres  of  the  anterior  roots  were  also  gray  and  degenerated. 
In  the  lower  third  of  the  dorsal  region,  the  txoo  anterior  horns  were  of  a 
very  marked  deep  gray  color,  contrasting  strongly  with  the  hue  of  the 
gray  matter,  which  had  become  transformed  into  pus.  In  the  middle  of 
the  lumbar  enlargement,  the  anterior  horns  were  softened  and  almost 
fluid.  This  was,  therefore,  a  case  of  central  myelitis  extending  to  the 
anterior  horns,  and  which  had  presented,  on  account  of  the  partial  re- 
covery of  the  paralyses,  the  same  symptoms  as  infantile  spinal  paralysis. 

A  few  years  later  Gombault  published  a  very  complete  and  clear  ob- 
servation (Arch,  de  Physiol.,  Jan.,  1873).  A  woman  was  affected  with 
paralysis  of  all  the  limbs,  coming  on  within  half  an  hour.  This  was 
followed  by  atrophy  of  the  muscles  with  loss  of  electrical  excitability; 
afterwards  improvement  progressed  slowly  for  several  months.  The  atro- 
phy and  paralysis  were  especially  marked  in  the  extensors  of  the  forearm 
and  in  the  interossei  and  muscles  of  the  thenar  eminence,  the  hand  being 
slightly  "  en  griffe."  The  patient  died,  within  a  year  and  a  half,  from 
intercurrent  carcinosis.  The  autopsy  revealed  pigmentary  atrophy  of 
the  large  ganglion-cells  of  the  anterior  horns,  especially  in  the  cervical 
and  lumbar  enlargements.  The  anterior  roots  and  the  affected  nerve- 
trunks  had  partially  undergone  fibroid  degeneration  ;  the  degenerations, 
to  which  we  have  previously  referred,  were  found  in  the  muscles. 

In  a  very  recent  case,  published  by  Cornil  and  Lepine  (Gaz.  Med. 
de  Paris,  II.,  1875),  the  patient,  a  man  twenty-seven  years  of  age,  became 
affected  with  paralysis  of  the  legs  in  consequence  of  exposure.  Two 
years  later  the  paralysis  extended  to  the  arms,  attended  with  muscular 
atrophy,  diminution  or  loss  of  electrical  excitability,  and  preservation  of 
sensation.  The  patient  died  of  asphyxia,  and  the  microscopical  examina- 
tion of  the  cord  showed  marked  atrophy,  and,  in  places,  disappearance 
of  the  cells  of  the  anterior  horns,  sclerosis  of  the  gray  substance,  thick- 
ening of  the  vascular  walls,  general  sclerosis  of  the  lateral  columns  ex- 
tending from  above  downwards,  atrophy  of  the  anterior  roots,  and  granu- 
lar degeneration  of  the  muscles,  the  transverse  strife  being  still  recog- 
nizable. 

Bernhardt  has  recently  published  (Arch.  f.  Psychiatr.,  IV.,  Bd.,  1873) 


10  CLINICAL    TEEATISE    ON 

three  observations  upon  the  same  disease,  occurring  in  adult  males.  I 
have  myself  seen  a  patient  seized,  after  severe  exposure,  with  paralysis  of 
all  the  limbs,  which  became  complete  within  a  short  period.  During  the 
entire  course  of  the  disease,  which  lasted  several  months,  there  were  no 
fever,  cerebral  symptoms,  spasms  or  disorders  of  sensation;  the  sphincters 
acted  regularly.  Marked  muscular  atrophy  was  manifested  in  the  hands; 
the  muscular  contractility  had  disappeared  at  the  end  of  several  days, 
and  reappeared  very  slowly  and  gradually.  The  galvanic  excitability  had 
suffered  less,  and,  in  the  beginning,  it  was  even  increased.  The  volun- 
tary movements  then  returned,  but  without  keeping  pace  with  the  dis- 
appearance of  the  electrical  symptoms.  The  patient  could  only  walk 
after  the  end  of  a  year,  but  he  still  manifested  very  great  weakness  and 
difficulty  in  executing  the  simplest  movements.  Cuming,  Frey,  Erb,  and 
others  have  also  published  cases  of  this  disease,  which  is  also  known  as 
poliomyelitis  anterior  acuta  (Kussmaul),  or  tephromyelitis  (Charcot). 

I  have  seen  a  case  in  which  poliomyelitis  anterior  presented  the  characteristics  of 
a  cervical  paraplegia,  and  terminated  in  recovery.  A  merchant,  aged  fifty  years,  was 
suddenly  attacked  with  fever  and  diarrhoea,  after  severe  exposure.  These  symptoms 
disappeared,  but  weakness  of  the  legs  supervened,  followed,  four  weeks  later,  by 
paralysis  of  both  arms.  At  the  end  of  six  months  I  found  moderate  paresis  in  the 
legs,  whose  galvanic  excitability  was  merely  dimir.ished  in  intensity.  Both  arms  and 
forearms  were  markedly  atrophied  and  paralyzed,  together  with  the  hands,  which  were 
dependent,  flexed  and  adducted,  with  very  marked  atrophy  of  the  first  interosseous 
space  and  of  the  thenar  eminence.  "When  the  radial  nerves  were  stimulated,  the  long 
supinators  and  flexors  of  the  wrist  alone  responded.  The  f  aradic  contractility  had  dis- 
appeared upon  both  sides  in  the  extensors  of  the  fingers  (even  in  the  left  hand,  in  which 
active  extension  of  the  wrist  was  still  possible).  The  galvanic  reaction  was  present, 
but  it  was  slow,  and  the  contractions  upon  closure  predominated  at  the  anode.  The 
muscles  of  the  first  interosseous  space  and  of  the  thenar  eminence  had  lost  their  ex- 
citability. Sensibility  was  intact,  but  the  sphincters  performed  their  functions  prop- 
erly. Under  the  influence  of  hydropathic  and  galvanic  treatment,  the  lower  limbs 
completely  recovered  at  the  end  of  several  months,  while  two  years  passed  before  the 
upper  limbs  recovered  suflBciently  to  enable  the  patient  to  write.  Nevertheless,  the 
faradic  and  galvanic  excitability  were  only  incompletely  restored. 

All  the  cases  which  we  have  reported  are  characterized  by  their  acute 
onset,  the  preservation  of  sensation,  the  absence  of  trophic  disturbances 
of  the  skin  (bed-sores),  and  muscular  atrophy  with  loss  of  electrical  con- 
tractility. These  cases  likewise  agree  in  their  principal  characteristics 
with  infantile  spinal  paralysis.  Histological  investigations  also  confirm  the 
relationship  of  these  two  affections.  They  merely  vary  in  certain  pecu- 
liarities depending  upon  the  difference  in  age  (more  rapid  and  complete 
atrophy  of  the  nerve-cells  in  children).  The  form  which  has  been  re- 
cently described  under  the  name  of  subacute  anterior  sjnncd  paralysis  (the 
same  symptoms,  but  following  a  slow  and  apyretic  course)  should  be  re- 
garded as  a  variety  of  spinal  paralysis  of  the  adult. 


DISEASES    OF    THE    NEEVOUS    SYSTEM.  11 


CHAPTER  XXV. 


PKOGKESSIVE    MUSCULAR   ATROPHY. 


The  peculiar  symptoms  of  this  affection  did  not  escape  the  attention 
of  Charles  Bell,  the  founder  of  nervous  pathology.  Other  observa- 
tions were  afterwards  published  by  Darwall,  Abercrombie,  Graves,  Du- 
bois, and  Romberg.  At  that  time  the  disease  was  supposed  to  be  a  local 
process  in  the  muscles.  Aran  (Arch.  Gener.,  Sept.,  1850)  was  the  first  to 
call  attention  to  the  extremely  characteristic  appearance  of  these  muscular 
paralyses,  and  has  mentioned  the  following  as  the  chief  symptoms  :  the 
loss  of  nutrition,  and,  at  the  same  time,  of  the  functions  of  the  muscles, 
and  the  extension  of  these  phenomena  to  larger  or  smaller  groups  of  mus- 
cles. To  Duchenne  is  due  the  credit  of  rendering  the  diagnosis  and  prog- 
nosis of  muscular  atrophy  more  exact  by  his  investigations  with  the  fara- 
dic  current,  and  of  clearing  up  the  physiological  pathology  of  its  symp- 
toms. But  full  information  upon  the  situation  and  nature  of  progressive 
muscular  atrophy  and  allied  affections  has  only  been  furnished  by  the  re- 
cent advances  in  histology  and  the  discover^'  of  the  degenerations  of  the 
anterior  gray  columns. 


Pathological  Anatomy  and  Experimental  Investigations. 

The  data  furnished  by  the  older  autopsies  are  as  follows  :  the  first  ob- 
servation is  that  made  by  Cruveilhier,  who  found,  in  one  case  (Arch.  Gener., 
1853),  very  marked  atrophy  of  the  anterior  nerve-roots.  Shortly  after- 
wards, Valentiner  (Prag.  Vierteljschr.,  1855)  observed,  in  addition  to  atro- 
phy of  the  anterior  roots,  a  central  softening  of  the  inferior  cervical  and 
lower  dorsal  regions  of  the  cord,  with  accumulation  of  granular  cells  in 
the  white  and  gray  substances.  Leubuscher  saw,  in  one  case  (Deutsche 
Klinik,  1857),  the  anterior  and  lateral  columns  transformed  into  an  amor- 
phous, doughy  mass,  of  a  whitish-gray  color,  with  acute  softening  of  the 
antero-lateral  columns  in  the  medulla  oblongata.  Analogous  results  have 
been  published  by  Read  and  Thouvenet,  and  later  by  Men  jaud,  Bamberger, 
Grimm,  and  Joffroy.  I  have  reported  (Ber.  Med.  Centralzeit.,  1871)  an 
old  observation  (dating  back  to  the  year  1865),  in  which  the  autopsy  re- 
vealed the  existence  of  atrophy  and  whitish-gray  coloration  of  the  left 
brachial  plexus,  extending  to  the  anterior  roots  of  the  thoracic  nerves  (the 
miscroscope  showed  amyloid  degeneration  of  a  portion  of  the  nerve-fibres). 

In  the  following  observations  the  degeneration  chiefly  affected  the 
gray  columns  of  the  cord:  Luys  (Gaz.  Med.,  1860,  granulo-fatty  cells  in  the 
anterior  horns)  ;  Lockhart  Clarke  (several  cases,  vide  Beale,  Arch,  of  Med., 
1861,  and  Med. -Chir.  Trans.,  1861,  1863,  1868,  1873);  Bergmann  (Petersb. 
Zschr.,  VII.  Bd.,  1865,  small  spots  of  softening  in  the  gray  svxbstance); 
Hayem  (Arch,  de  Phys.,  T.  II.,  1869) ;  Charcot  and  Joffroy  (eod.  loc,  1869), 


12  CLINICAL    TREATISE    ON 

chronic  pigmentary  atrophy  of  the  nerve-cells  of  the  anterior  horns  with 
atrophy  of  the  lateral  columns. 

The  atrophy  of  the  anterior  horns,  or  even  of  the  posterior  horns,  was 
accompanied  by  dilatation  of  the  central  canal  (central  cavity  filled  with 
fluid,  hydromyelitis)  in  the  observations  of  Gull  (Guy's  Hosp.  Rep.,  1862), 
Schueppel  (Arch.  d.  Heilk.,  1865),  and  Grimm  (Virch.  Arch.,  1869). 
Hydromyelitis  appears  to  consist  of  a  dropsical  distention  of  the  central 
canal,  with  partial  retraction  of  the  surrounding  tissue.  According 
to  others,  this  dilatation  of  the  canal  is  secondary  to  an  old  central  mye- 
litis. 

The  examples  of  atrophy  limited  to  the  anterior  or  posterior  roots,  or 
to  the  posterior  columns  (Virchow  and  Friedreich),  refer  to  observations 
made  twenty  years  ago,  and,  together  with  the  negative  results  obtained, 
at  the  same  period,  by  Oppenheimer,  Hasse,  Friedberg,  Menyon,  etc., 
have  lost  all  value  at  the  present  time.  These  statements  have  been  con- 
troverted by  positive  data,  which  are  continually  accumulating,  thanks  to 
the  more  complete  methods  of  investigation  of  modern  histology. 

Some  authors  were  led  to  explain  the  trophic  disturbances  by  a  scle- 
rosis of  the  cervical  portion  of  the  sympathetic  nerve  (Schneevogt,  Jac- 
coud,  Dumenil),  but  this  theory  has  also  lost  its  importance.  In  the  first 
place,  atrophy  of  the  anterior  horns  was  found  three  times,  and  softening 
of  the  cord  once,  in  the  cases  which  were  relied  upon  to  substantiate  this 
theory;  in  addition,  the  more  recent  and  complete  microscopical  exami- 
nations of  Frommann,  Hayem,  Charcot,  and  Joffroy,  and  the  older  investi- 
gations of  Friedreich  have  demonstrated  the  complete  integrity  of  the 
sympathetic  nerve  and  its  ganglia  in  progressive  muscular  atrophy. 

The  tissue  changes  which  the  muscles  present  upon  the  cadaver  cor- 
respond to  the  symptoms  observed  during  life.  Certain  muscles  preserve 
their  normal  red  color;  others,  on  the  contrary,  are  pale  or  even  of  a  gray- 
ish-yellow. Immediately  adjacent  muscles  frequently  present  very  differ- 
ent degrees  of  degeneration  ;  in  the  same  muscles  we  may  find  intact 
fibres  side  by  side  with  others  affected  with  fatty  degeneration.  The 
apparently  healthy  muscles  present  a  normal  consistence,  and  show  no 
changes  under  the  microscope.  Those  which  are  slightly  affected,  have 
lost,  to  a  greater  or  less  degree,  their  transverse  or  longitudinal  striae, 
and  contain  cells  or  fatty  drops,  of  variable  number  and  dimensions,  in 
the  interior  or  in  the  interspaces  of  the  fibres.  The  most  seriously  af- 
fected muscles  are  softened,  gelatinous,  and  transformed  into  a  transpa- 
rent, amorphous  fatty  matter.  According  to  Virchow,  the  fatty  degener- 
ation may  either  occur  between  the  primitive  fibres  (parenchymatous 
form),  or  in  the  interfibrillary  tissue  (interstitial  form) ;  both  forms  may 
also  coexist. 

The  progressive  degeneration  of  the  cells  of  the  anterior  horns,  which 
constitutes  the  fundamental  lesion  of  progressive  muscular  atrophy,  may 
he  primary  and  entirely  independent  of  any  other  spinal  lesion.  On  the 
other  hand,  it  is  secondary  in  very  many  cases.  The  lesions  are  then  first 
developed  in  the  columns  of  the  cord,  from  whence  they  extend  to  the  an- 
terior part  of  the  gray  columns. 

Among  the  morbid  processes,  whose  pathological  influence  upon  the 
secondary  degeneration  of  the  anterior  gray  columns  of  the  cord  and  up- 
on progressive  muscular  atrophy  has  been  recently  recognized,  we  may 
mention  cerebral  apoplexy,  in  which  the  sclerosis  of  the  lateral  columns 
may  sometimes  extend  forwards  (Charcot);  labio-glosso-pharyngeal  paral- 
ysis, in  which  the  lesion  of  the  bulbar  nuclei  may  extend  to  the  anterior 


DISEASES    OF   THE    NERVOUS    SYSTEM.  13 

part  of  the  cord;  central  myelitis,  in  which  the  anterior  part  of  the  gray 
axis  of  the  cord  may  participate  in  the  degeneration  either  primarily  or 
secondarily  (traumatism,  tumor) ;  cerebro-spinal  sclerosis,  the  sclerosis  of 
the  posterior  columns  in  ataxia,  and  symmetrical  sclerosis  of  the  lateral 
columns  (amyotrophic  lateral  sclerosis  of  Charcot),  when  they  also  attack 
the  anterior  horns;  finally,  meningo-myelitis  in  vertebral  caries  (Hayem), 
and  hypertrophic  spinal  pachymeningitis  (Charcot),  which  we  have  pre- 
viously discussed,  may  produce  compression-lesions  of  the  anterior  horns 
and  roots. 

Hayem  (Compt.  Rend.  Ac.  des  Sc,  LXXVIIL,  1874)  has  experimen- 
tally produced  progressive  muscular  atrophy  in  animals,  by  tearing  out, 
or  by  simple  incision  of,  the  sciatic  nerve.  If  the  animals  survived  the 
experiment  two  or  three  months,  they  presented,  at  first,  progressive 
muscular  atrophy  in  the  posterior  limb  upon  the  side  opposite  to  the 
lesion.  Afterwards  it  also  involved  the  anterior  limbs  and  the  muscles 
dependent  on  the  bulbar  nuclei.  The  autopsy  showed  the  presence  of 
hemorrhagic  perimeningitis  and  generalized  central  myelitis  with  in- 
tense hyperagmia  of  the  gray  substance,  numerous  extravasations  and 
exudations  into  the  central  canal,  and  degeneration,  advancing  even  to 
complete  destruction,  of  the  groups  of  anterior  nerve-cells.  By  simple 
contusion  of  the  gray  substance  of  the  cord,  Vulpian  has  been  unable  to 
produce,  in  animals,  atrophy  of  the  muscles  whose  nerves  originate  in 
the  wounded  part  of  the  cord. 


Miology. 

Sexual  excesses,  especially  onanism — upon  which  great  stress  has  been 
laid  by  some  authors — and  exposure,  give  rise  to  only  a  small  proportion  of 
cases  of  the  disease  under  consideration.  The  same  may  be  said  of  acute 
diseases.  Roberts,  Gerhardt,  and  Nesemann  have  seen  cases  develop  after 
typhoid  fever,  rubeola,  and  scarlatina;  in  one  of  my  patients  the  disease  ap- 
peared six  months  after  an  attack  of  variola.  Acute  articular  rheumatism 
( Anstie,  Friedreich),  the  puerperal  condition  (Charcot  and  Joffroy),  and  the 
typhoid  form  of  cholera,  are  also  mentioned  as  causes  of  progressive  mus- 
cular atrophy.  The  influence  of  heredity  has  been  observed  in  a  certain 
number  of  cases  ;  Roberts  has  noted  it  eighteen  times  in  sixty-nine  cases. 
In  an  observation  which  I  published  in  detail  (Wien.  med.  Halle,  3863), 
the  disease  was  produced  by  a  fall  from  a  roof;  the  concussion  (which 
had  produced  double  fracture  of  the  ribs  in  the  neighborhood  of  the 
spinal  column)  had,  undoubtedly,  also  produced  lesions  in  the  cord.  Rus- 
sel-Reynolds  and  Bergmann  have  each  published  a  case  of  atrophy 
following  traumatism. 

The  over -exertion  to  which  certain  groups  of  muscles  are  subjected  in 
certain  occupations  exercises  a  very  evident  influence  upon  the  develop- 
ment of  progressive  muscular  atrophy.  For  this  reason  we  find  a  large 
number  of  cases  in  the  working-classes,  and  a  much  greater  frequency  of 
the  disease  in  the  upper  limbs,  and  more  especially  in  the  small  muscles 
of  the  thumb  and  other  fingers.  We  can  often  recognize  the  evident 
influence  of  the  predominant  action  of  one-half  of  the  body  during  work. 
Thus  I  have  seen  a  laboring  man,  who  removed  considerable  masses  of 
earth  with  the  spade  and  pick,  and  in  whom  the  muscles  of  both  shoulders 
were  atrophied  and  paralyzed,  to  the  exclusion  of  the  arms  and  forearms, 
which  were  normal.     In  a  weaver,  who  plied  the  shuttle  with  the  thumb 


14 


CLINICAL    TREATISE    ON 


and  index-finger  of  the  left  hand,  these  two  fingers  were  first  and  most 
seriously  affected  by  the  atrophy  and  paralysis.  A  workman  was  em- 
ployed in  a  brewery  to  hermetically  close  large  bottles  ;  he  wielded  a 
heavy  hammer  with  the  right  hand,  and  the  muscles  of  the  shoulder  were 
first  affected  upon  this  side,  while  in  the  left  hand,  which  held  the  bottles, 
the  atrophy  involved  all  the  muscles  of  the  fingers,  those  of  the  arm  and 
shoulder  remaining  intact. 

Males  are  more  subject  to  progressive  muscular  atrophy  than  females, 
on  account  of  their  more  arduous  labors  and  great  exposure  to  noxious 
influences.  According  to  Friedreich's  statistics,  females  only  constitute 
eighteen  per  cent,  of  the  whole  number  of  cases.  There  is  also  a  greater 
congenital  predisposition  in  the  male  sex.  The  largest  number  of  cases 
occur  between  the  ages  of  thirty  and  fifty  years;  the  disease  has  few 
victims  above  or  below  these  limits. 


1 


Symptomatology. 

Progressive  muscular  atrophy  (atrophic  progressive  muscular  atrophy 
of  Cruveilhier,  wasting  palsy  of  the  English)  is  usually  characterized, 
during  the  first  periods  of  the  disease,  by  certain  symptoms  of  irrita- 
tion on  the  part  of  sensation  and  motion.  In  the  beginning  the  pa- 
tients frequently  experience  a  sensation 
of  a  current  of  cold  air,  formication,  numb- 
ness, wandering  pains,  and  complain  that 
the  arm  or  hand  is  easily  fatigued.  Every 
exertion  causes  tremor;  they  suffer  from 
spasms  and  tension  in  the  muscles;  the  fin- 
gers become  stiff,  and  remain  applied  to  one 
another.  As  a  rule,  the  muscular  tissue 
first  atrophies  in  the  thumb  and  hypothe- 
nar  eminence;  the  movements  of  opposition 
and  abduction  of  the  thumb  are  lost,  the 
hand  and  fingers  lose  their  agility,  the  lat- 
ter become  more  and  more  curved,  the  in- 
terosseous spaces  are  markedly  hollowed 
out.  The  atrophy  and  paralysis  of  the 
small  muscles  of  the  hand,  and  the  great- 
er tension  of  the  antagonists,  of  the  ex- 
tensors and  flexors  of  the  phalanges,  situ- 
ated in  the  forearm,  gives  to  the  retraction 
of  the  hand  (according  to  Duchenne)  the 
appearance  of  a  claw  (griffe  de  la  main : 
clasped  hand,  or  claw-shaped  hand).  The 
forearm  soon  becomes  more  and  more  flat- 
tened (especially  on  the  extensor  side), 
and,  during  this  time,  the  atrophy  extends 
to  other  muscles,  to  the  shoulder  (which 
appears  angular  and  oblique)  and  to  the 
trunk  (atrophy  of  the  deltoid,  trapezius,  pectoralis  major,  muscles  of  the 
neck,  back,  and  abdomen).  Afterwards  the  atrophy  and  paralysis  also 
extend  to  the  lower  limbs  and  ultimately  to  the  respiratory  muscles  and 
to  the  tongue  and  pharynx.      (Fig.  16.) 

The  affection  does  not  always  produce  the  same  disorders  in  the  upper 


Fig.  16  — I'lMU'ic -.m  inii-(  ul.ir  atro- 
phy, involving  the  muscles  o£  the  trunk 
and  upper  extremities. 


DISEASES    OF    THE    NEEVOUS    SYSTEM.  15 

limbs.  The  atrophy  appears  most  frequently  and  runs  its  course  most 
rapidly  in  the  small  muscles  of  the  fingers,  in  those  which  move  the 
wrist,  in  the  muscles  of  the  arm  and  forearm,  and  then  in  the  shoulders. 
Paralysis  of  the  rotators  of  the  humerus  backwards  (infraspinatus  and 
teres  minor)  is  combined  with  that  of  the  deltoid.  If  the  latter  muscle 
(the  principal  elevator  of  the  arm)  becomes  paralyzed,  the  adjacent  mus- 
cles of  the  shoulder  (trapezius,  rhomboid,  serratus  magnus)  will  supple- 
ment its  action;  but  after  a  time  they  succumb,  as  have  the  others,  to  this 
unusual  expenditure  of  force.  The  atrophy  is  generally  bilateral,  affect- 
ing symmetrical  groups  of  muscles;  but  this  rule  is  not  without  excep- 
tions. More  rarely  the  affection  begins  in  the  shoulder  and  extends  up- 
wards or  downwards,  or  it  has  several  points  of  departure  at  the  same 
time. 

Dull  pains  (but  sometimes  of  a  tearing  or  lancinating  character)  are 
soon  added  to  the  disorders  of  nutrition  and  motion.  They  are  either 
diffuse,  or  follow  the  tract  of  certain  nerves;  they  occur  periodically,  and 
are  usually  mistaken  for  rheumatism.  The  shoulders  then  become  flattened, 
the  scapulas  are  often  separated  from  the  trunk,  deflected,  and  limited  in 
their  movements,  and  this  region  becomes  the  seat  of  distressing  neural- 
gic pains.  Reflex  excitability  is  not  infrequently  increased  from  the  be- 
ginning. The  motor  symptoms  of  irritation  consist,  in  the  first  stages, 
of  clonic,  sometimes  tonic,  muscular  spasms.  Fibrillary  twitchings  occur 
in  the  muscles  at  a  later  period,  and  either  develop  spontaneously,  or 
after  movement  (in  one  case  I  observed  them  very  distinctly  in  the 
tongue).  In  certain  cases  the  shortening  and  retraction  of  the  muscles 
produce  contractures  and  subluxations  of  the  knees  and  feet,  or  even 
scoliosis  of  the  vertebral  column. 

The  atrophy  and  paralysis  do  not  always  folloio  the  same  course. 
Paralysis  may  appear  without  notable  change  in  the  nutrition  (we  must 
take  into  consideration,  in  such  cases,  the  proliferation  of  the  interstitial 
connective  and  adipose  tissue).  On  the  other  hand,  markedly  atrophied 
muscles  may  preserve  their  functions.  But  in  the  advanced  stages  of  the 
disease  the  paralysis  and  atrophy  of  the  muscles  go  on  hand  in  hand. 
Baerwinkel  and  Frommann  have  noticed  an  elevation  of  temperature  at 
the  onset.  At  a  later  period,  after  the  abolition  of  the  muscular  func- 
tions and  the  lowering  of  nutrition,  the  temperature  falls  2°,  3°,  and  even 
4°  C.  (Eulenburg,  Duchenne,  R.  Reynolds,  and  Friedreich).  (I  have  noted 
this  fact  in  two  cases  by  measurements  in  the  axilla  and  upon  different 
muscles.)  For  the  same  reasons,  the  amount  of  creatine,  which  is  a  prod- 
uct of  intra-muscular  nutritive  changes,  diminishes  sensibly  in  the  urine 
(analysis  has  shown  this  in  three  of  my  patients).  These  facts  may  be 
logically  deduced  from  the  continuous  deterioration  of  muscular  nutrition. 

Interesting  ocido-pupillary  symptoms  sometimes  develop,  as  I  have 
observed  in  several  cases.  In  these  instances,  one  of  the  pupils  (usually 
that  upon  the  most  affected  side)  is  contracted  to  less  than  half  its  nor- 
mal size,  and  reacts  slightly  or  not  at  all  to  light.  The  dilatation  follow- 
ing the  introduction  of  atropine  only  disappears  after  the  lapse  of  ten 
or  twelve  days.  The  contraction  of  the  pupils,  caused  by  contraction  of 
the  radiating  fibres,  only  appears  when  the  affection  extends  as  high  as 
the  cilio-spinal  centre,  or  when  the  latter  is  under  the  influence  of  ascend- 
ing lesions  of  the  cervical  cord.  Schneemann,  Voisin,  Menjaud,  and  Berg- 
mann have  also  reported  analogous  observations.  In  Menjaud's  case  (Gaz. 
des  Hop.,  Jan.,  1866)  contraction  of  the  left  pupil  occurred  with  flatten- 
ing of  the  cornea.     The  last  pairs  of  cervical  and  the  first  pairs  of  dorsal 


IQ  CLINICAL    TREATISE    ON 

nerves  were  found  atrophied,  more  markedly  on  the  left  side  (the  central 
foyer  of  the  fibres  of  the  iris  is  situated  in  the  corresponding  portion  of 
the  cord).  CI.  Bernard  has  made  an  experiment  which  confirms  these 
pathological  observations.  After  having  divided  the  anterior  roots  in 
dogs,  he  saw  contraction  of  the  pupil  soon  develop,  with  flattening  of  the 
cornea,  and  sinking  in  of  the  eyeball,  but  without  increase  of  vasculariza- 
tion or  of  the  temperature.  On  the  other  hand,  the  latter  symptoms  were 
immediately  observed  after  section  of  the  ascending  branch  of  the  tho- 
racic sympathetic,  while  the  condition  of  the  pupils  underwent  no  change. 

The  following  tro2yhic  disturbances  have  been  observed:  herpes  (in  one 
of  my  patients,  along  the  radial  nerve  of  the  atrophied  arm) ;  the  combina- 
tion of  the  disease  with  fatty  muscular  hypertrophy  (one  observation  by 
Friedreich,  another  by  myself,  with  shapeless  thickening,  at  first  in  the 
middle  fingers  and  then  in  the  others);  finally,  the  very  rare  complication 
with  hypertrophy  of  the  bones  (enlargement  of  the  metacarpus,  according 
to  Remak),  with  concentric  osseous  atrophy  (Le  Gendre  and  Friedreich) 
and  with  arthropathies  (noted  by  Patruban,  Remak,  and  m.yself).  The 
ease  which  I  observed  occurred  in  a  woman,  fifty  years  of  age,  suffering 
from  progressive  muscular  atrophy  of  both  arms.  In  the  third  year  of 
the  disease,  the  lower  limbs  also  became  involved,  and  the  right  shoulder 
became  swollen  until  it  almost  attained  the  size  of  a  child's  head,  without 
the  least  pain  or  sign  of  inflammation;  matters  remained  in  this  condition 
for  a  year.  Towards  the  end  of  the  fourth  year,  the  paralyzed  limbs 
were  reduced  to  skeleton-like  proportions.  Incontinence  of  urine  and 
faeces  and  bed-sores  over  the  sacrum  developed,  and  the  patient  died  of 
intercurrent  pneumonia  of  the  right  lung.  An  autopsy  could  not  be  ob- 
tained. 

Finally,  electrical  exploration  gives  different  results  according  to  the 
stage  of  the  muscular  affection.  The  electro-muscular  contractility  is 
normal  in  the  healthy  muscles;  in  the  affected  muscles  it  is  either  dimin- 
ished or  increased.  At  a  more  advanced  stage  of  the  disease,  voluntary 
impulse  may  still  be  transmitted  by  the  nerves  and  produce  contraction 
of  certain  muscles,  although  this  can  no  longer  be  obtained  by  electrical 
irritation  on  account  of  its  peripheral  origin  and  of  the  intra-muscular 
changes.  This  abolition  of  electro-muscular  contractility  is  soon  followed 
by  loss  of  voluntary  motion.  The  galvanic  excitability  of  the  nerve- 
trunks  is  increased  in  certain  branches;  in  others,  on  the  contrary,  it  may 
be  normal  or  even  diminished.  It  may  be  preserved  in  the  nerve-fila- 
ments nearest  to  the  centres,  and  diminished  in  the  peripheral  ramifica- 
tions. 

This  is  due  to  the  differences  in  the  secondary  changes  in  the  various 
branches  of  the  nerves.  In  mixed  nerve-trunks,  sensibility  remains  intact 
for  a  longer  time  than  motion.  The  weakened  galvano-muscular  con- 
tractility may  persist  for  a  longer  time  than  the  previously  affected  faradic 
contractility.     (For  further  details,  vide  the  preceding  chapter.) 

Remak  has  called  attention  to  the  increase  of  electrical  reflex  excita- 
bility, and  to  the  diplegic  contractions  produced  by  the  stimulation  of  two 
distant  parts  of  the  muscles.  The  diplegic  contractions  may  be  obtained, 
according  to  Eulenburg,  over  the  entire  or  larger  portion  of  the  surface  of 
the  body.  These  are  true  reflex  contractions,  whose  origin  must  be 
sought  in  the  reflex  apparatus  of  the  spinal  cord  and  medulla  oblongata, 
but  they  may  also  be  observed  in  cases  of  exaggerated  excitability  of  the 
muscles. 

Progressive  muscular  atrophy  generally  runs  a  chronic  course  ;  even 


DISEASES    OF   THE    NERVOUS    SYSTEM.  17 

when  it  is  hereditary,  the  disease  does  not  prevent  the  patient  from  at- 
taining an  advanced  age.  I  have  observed  one  case  which  lasted  more 
than  twenty  \ea.Ts  ;  at  other  times  the  patients  may  die  during  the  first 
years  of  the  disease.  Duchenne  considers  the  affection  less  serious  when 
it  proceeds  from  the  muscles  of  the  trunk  than  when  it  begins  in  the 
hands  and  extends  upwards.  When  the  muscles  of  respiration  and  de- 
glutition are  affected  at  an  early  period,  the  danger  may  rapidly  attain 
its  maximum.  But,  happily  for  the  patient,  this  does  not  generally  occur 
until  towards  the  close  of  the  disease. 


The  JVature  of  Progressive  Muscular  Atrophy. 

Since  the  clinical  picture  of  progressive  muscular  atrophy  has  been 
completely  unveiled,  and  pathological  anatomists  have  devoted  all  their 
zeal  to  the  solutions  of  the  problems  which  this  affection  presents,  the  most 
diverse  data  have  been  accumulated,  and  have  led  to  a  very  decided  differ- 
ence of  opinion.  Observers  are  divided  into  two  camps,  each  of  which 
numbers  equally  celebrated  names  among  its  adherents.  Among  the  ad- 
vocates of  the  theory  of  the  central  nature  of  the  disease,  we  may  men- 
tion Cruveilhier,  Valentiner,  Remak,  Frommann,  Virchow,  Charcot  and 
Joffro}^,  L.  Clarke,  Hayem  and  Duchenne.  Among  the  defenders  of  its 
primary  myopathic  origin  are  included  Arat,  Meryon,  Wachsmuth,  Op- 
penheimer,  Hasse,  Friedberg,  and  Roberts,  The  latter  theory  has  been 
recently  supported  with  especial  zeal  by  Friedreich  [vide  a.\ong  and  inter- 
esting monograph  by  this  author:  Ueber  progressive  Muskelatrophie,  etc., 
Berlin,  1873).  If  we  examine  the  arguments  advanced  by  this  authori- 
tative representative  of  the  myopathic  theory,  we  will  find  that  Friedreich 
regards  progressive  muscular  atrophy  as  an  intra-muscular  inflammatory 
process,  which  begins  with  hyperplasia  of  the  interstitial  connective  tissue, 
and  terminates  in  atrophy  and  separation  of  the  muscular  elements,  in 
waxy  or  fatty  degeneration,  and,  finally,  in  a  fibrous  transformation  of 
the  muscular  fibres.  Diffuse  fatty  degeneration  often  occurs  as  an  acces- 
sory phenomenon.  This  progressive  chronic  myositis  is  capable  of  produc- 
ing secondary  disorders  in  the  nervous  system,  by  extension  of  the  lesions 
to  the  intra-muscular  nerves,  and  by  neuritis,  extending  along  the  nerve- 
trunks,  plexuses,  and  anterior  roots,  to  the  spinal  cord. 

In  order  to  establish  his  theory,  Friedreich  calls  attention  to  the  sim- 
ilarity in  the  histological  changes  of  the  muscular  tissue  in  atrophy  and 
in  other  forms  of  muscular  inflammation;  to  the  tendency  of  progressive 
muscular  atrophy  to  be  arrested,  in  its  extension,  by  the  large  articula- 
tions; to  the  variability  of  the  lesions  in  different  parts  of  the  nervous 
system,  as  we  find  by  several  examples  in  medical  literature;  to  the  fre- 
quent predominance  of  the  changes  in  the  anterior  roots  as  compared  with 
those  in  the  cord;  to  the  negative  results  of  examinations  of  the  cord, 
noted  several  times  in  foreign  observations  and  in  his  own  (one  of  them 
was  even  complicated  with  bulbar  paralysis);  finally,  to  the  fact  that 
atrophy  of  the  ganglion-cells  develops,  secondarily,  as  has  been  observed 
after  amputations,  in  consequence  of  prolonged  abolition  of  the  muscular 
functions. 

It  appears  to  me  that  this  full  expose  of  Friedreich's  arguments  can  be 
responded  to  by  facts  equally  well  proven  and  well  founded.  We  base 
our  opposition  upon  the  data  furnished  by  anatomy  and  clinical  obser- 
vation. From  the  former  point  of  view,  we  may  refer  to  the  fact  that^  in 
Vol.  II.— 2 


18  CLIlSriCAL    TKEATISE    ON 

acute  myelitis,  we  also  observe  nuclear  proliferation  of  the  sarcolemma, 
fatty  degeneration  of  the  primitive  fibrillfe,  and  even,  if  the  patients  have 
survived  the  attack  for  a  long  time,  considerable  atrophy  of  the  muscles. 
Progressive  muscular  atrophy  is  not  always  arrested  at  the  articulations, 
andeven  when  this  does  occur,  it  may  be  explained  by  the  fact  that 
muscles  with  synergic  action  are  also  limited  by  the  articulations,  and 
that  their  ganglion-cells  probably  form  distinct  groups  in  the  cord. 
Since,  moreover,  the  same  group  of  cells  may  furnish  fibres  to  differ- 
ent peripheral  muscles,  we  can  comprehend  the  leaps  made  by  pro- 
gressive muscular  atrophy  in  its  development,  while  a  parenchymatous 
muscular  inflammation  should  follow,  in  its  course,  the  anatomical  con- 
tinuity of  the  organs.  With  regard  to  the  inconstancy  of  the  anatomical 
lesions  in  the  different  paths  of  the  central  nervous  system,  and  to  the 
cases  in  which  negative  results  were  obtained,  it  may  be  stated  that  all 
these  facts  relate  to  a  former  period,  in  which  the  methods  of  examination 
now  at  our  command  were  unknown.  We  now  find  lesions  of  the  gray 
substance  more  frequently  and  constantly  ;  the  fact  has  also  been  recog- 
nized that  degeneration  of  the  anterior  roots  is  not  always  proportional 
to  the  amount  of  change  in  the  gray  horns.  Finally,  the  argument  drawn 
from  the  analogy  in  the  secondary  atrophy  which  the  cells  present  after 
amputations,  is  not  well  founded,  for,  according  to  Vulpian,  Clarke,  and 
Dickinson,  we  never  find,  in  these  cases,  disappearance  or  deformity  of 
the  ganglion-cells  or  new-formed  connective  tissue,  but  merely  a  simple 
atrophy  of  the  cells,  with  coexisting  atrophy  in  the  corresponding  part 
of  the  cord. 

From  a  clinical  point  of  view,  many  symptoms  indicate  the  spinal 
origin  of  the  disease;  the  dorsal  pains  wliich  sometimes  appear  at  the  on- 
set; the  neuralgia  of  the  limbs;  the  frequency  of  spasmodic  symptoms, 
and  increase  of  reflex  excitability;  the  peculiar  reactions  of  the  muscles 
and  nerves  to  the  galvanic  current  ;  the  paralysis  of  the  sphincters  and 
the  impotence  observed  by  Cruveilhier,  Tardieu,  and  myself;  the  compli- 
cation with  bulbar  paralj'sis,  ataxia,  and  myelitis;  finally,  the  trophic  dis- 
turbances (rare,  it  is  true)  of  the  bones  and  articulations.  In  the  same 
manner  that  excesses,  onanism,  and  over-exertion  produce,  in  predisposed 
subjects,  the  medullary  degenerations  of  ataxia  or  myelitis,  so  also  the 
atrophy  and  deformity  of  the  cells  of  the  anterior  horns  may  be  due  to 
excessive  use  of  certain  muscles,  which  is  sometimes  added  to  bad  habits 
of  life  as  a  pathogenic  factor. 

The  myopathic  theory  is  entirely  incapable  of  explaining  certain  well- 
known  forms  of  progressive  muscular  atrophy,  which  accompany  diseases 
of  an  evidently  central  nature.  In  central  myelitis  of  a  rapid  course,  in 
the  acute  spinal  paralysis  of  adults,  in  tumors  of  the  gray  substance,  in 
sclerosis  of  the  posterior  or  lateral  columns  extending  to  the  gray  sub- 
stance, progressive  muscular  atrophy  may  develop,  as  we  have  shown 
above,  both  clinically  and  physiologically,  from  the  extension  of  the 
degeneration  to  the  cells  of  the  anterior  horns  and  the  intra-medullary 
anterior  root-fibres.  The  microscope,  by  clearing  up  the  minute  lesions 
of  the  anterior  gray  columns,  has  definitely  fixed  our  information  con- 
cerning various  morbid  processes  of  the  nerve-centres,  and  from  this  alone 
we  are  able  to  thoroughly  understand  the  pathogeny  &f  the  affection. 

We  therefore  think,  in  view  of  the  preceding  arguments,  that  the  at- 
tacks of  Friedreich  will  be  unable  to  shake  the  position  of  the  nervous 
theory,  which  is  daily  becoming  more  solid  and  unassailable.  Progressive 
muscular  atrophy,  in  the  larger  number  of  its  forms,  originates  in  the  cen- 


DISEASES    OF    THE    NEEVOUS    SYSTEM.  19 

tral  gray  axis;  the  changes  in  the  antero-lateral  columns  are  rather  sec- 
ondary and  accessory.  According  to  the  experiments  of  Hayem  and  the 
clinical  observations  which  he  has  reported,  there  is  only  a  yery  small 
number  of  varieties  in  which  we  are  justified  in  assuming  that  myelitis  of 
the  anterior  gray  columns  is  secondary  to  irritation  of  the  nerves  and  their 
roots.  Among  the  causes  of  these  rare  forms  of  progressive  muscular  at- 
rophy, we  may  mention  meningo-myelitis  and  pachymeningitis,  of  which 
we  have  spoken  in  the  beginning  of  this  work,  and  the  sclerosis  of  the 
anterior  horns,  complicating  degeneration  of  the  inner  root-fibres,  in  ataxia. 


Diagnosis  and  Prognosis. 

In  the  clinical  history  of  progressive  muscular  atrophy,  the  peculiar 
atrophy  of  the  muscular  system,  the  emaciation,  the  deformity  of  the 
limbs  and  trunk,  and  the  electrical  reactions,  either  in  muscles  still  intact 
or  in  their  remains,  impress  the  disease  with  such  a  characteristic  seal, 
that  the  diagnosis  can  almost  always  be  made  at  the  first  inspection  of 
the  patient.  There  are,  nevertheless,  cases  in  which  certain  symptoms,  of 
a  different  nature,  may  lead  us  to  form  an  erroneous  diagnosis.  It  will 
not  be  superfluous,  in  view  of  these  cases,  to  refer  to  the  principal  ele- 
ments in  differential  diagnosis. 

In  spinal  menbigitis,  the  unequal  compression  exercised,  by  the  exu- 
dation, upon  the  nerve-roots  may  also  cause  marked  atrophy  of  the  limbs, 
paralyses,  and  abolition  of  electro-muscular  contractility.  But  in  these 
cases  the  active  movements  and  reflex  excitability  of  the  nerve-trunks 
have  already  disappeared,  in  great  part,  at  the  end  of  some  weeks,  a  fact 
which  does  not  obtain  in  progressive  muscular  atrophy.  In  addition,  the 
febrile  beginning,  the  tonic  spasms  of  the  neck,  the  painful  muscular  stiff- 
ness extending  throughout  the  trunk,  and  its  almost  always  notoriously 
rheumatic  origin,  establish  the  differential  diagnosis  from  spinal  menin- 
gitis very  clearly.      (  Vide  page  188,  Vol.  I.,  for  further  details.) 

Symmetrical  sclerosis  of  the  lateral  columns,  with  degeneration  of  the 
cells  of  the  anterior  horns  (amyotrophic  lateral  sclerosis,  described  for  the 
first  time  by  Charcot  in  Prog.  Med.,  1874),  is  distinguished,  according  to 
this  author,  from  progressive  muscular  atrophy,  by  its  rapid  course  (one  to 
three  years),  by  the  ultimate  affection  of  all  the  limbs,  the  upper  being 
more  completely  atrophied  and  paralyzed,  the  lower  being  simply  para- 
lyzed; by  the  almost  constant  extension  of  the  lesions  to  the  bulbar  nuclei 
(while,  according  to  Duchenne,  among  one  hundred  and  thirty-nine  cases 
of  progressive  muscular  atrophy  the  bulbar  nuclei  were  only  involved  thir- 
teen times);  by  the  prolonged  preservation  of  electro-muscular  comrac- 
tility;  finally,  by  the  permanent  spasmodic  contractures  of  the  paralyzed 
and  atrophied  limbs,  which  are  fixed  in  a  semi-flexed  position,  the  upper 
limbs  being  pronated. 

Infantile  S2nnal paralysis  has  also  many  symptoms  in  common  with 
progressive  muscular  atrophy,  but  the  latter  is  very  rare  in  childhood. 
We  have  given,  in  detail,  the  distinguishing  features  of  infantile  spinal 
paralysis  in  the  preceding  chapter. 

In  spondylitis  of  the  upper  segment  of  the  vertebral  column,  paralysis 
and  atrophy  of  one  arm  sometimes  occur  (a  case  of  this  kind  is  reported 
on  page  216,  Vol.  I.),  recalling  the  appearances  of  progressive  muscular 
atrophy.  The  condition  of  the  bodies  of  the  vertebrae,  the  pains  in  the 
vertebral  column  during  movements  of  rotation  or  flexion,  excentric  neu- 


20  CLINICAL    TREATISE    OIT 

ralgia  developing'  around  the  diseased  part,  and  the  unilateral  and  circum- 
scribed form  of  the  disease,  furnish  the  necessary  difPerential  data. 

Paralysis  and  emaciation  of  one  or  both  arms,  with  contracture  of  the 
fingers,  are  also  observed,  at  times,  in  hysteria.  In  such  cases  the  disor- 
ders of  sensation  (especially  anaesthesia),  the  diminution  and  disappear- 
ance of  electro-muscular  and  electro-cutaneous  sensibility,  with  slight  al- 
teration of  electro-muscular  contractility,  and  other  hysterical  symptoms, 
form  the  basis  of  diagnosis. 

General  lead  j^cilsy  of  both  upper  limbs  also  resembles,  in  some  points, 
progressive  muscular  atrophy.  But  even  in  the  more  advanced  forms, 
the  completely  pendent  hand  is  not  flexed  "  en  griffe,"  and  we  do  not  ob- 
serve entire  disappearance  of  the  muscles  of  the  thenar  and  hypothenar 
eminences.  They  have  preserved,  in  great  j^art,  their  electrical  contractil- 
ity, and  the  supinators  are  generally  intact.  In  the  majority  of  these 
cases  we  also  find  that  the  patients  have  worked  in  lead  and  have  suffered 
from  lead  colic;  ulceration  and  coloration  of  the  gums  and  obstinate  con- 
stipation likewise  occur. 

The  muscular  atrophy  and  deformity  of  the  hands,  which  accompany 
rheumatismus  nodosus,  have  the  following  characteristics:  painful  swelling 
of  the  smaller  and  larger  joints  and  of  the  epiphyses,  frequent  creaking 
and  ankyloses,  and,  even  in  old  cases,  intact  condition  of  the  electro-mus- 
cular contractility.  These  phenomena  are  not  observed  in  progressive 
muscular  atrophy.  Traumatic  lesions  of  the  cervical  and  brachial  plex- 
uses may  also  produce  symptoms  of  progressive  muscular  atrophy,  exam- 
ples of  which  will  be  found  in  the  chapter  on  traumatic  paralyses.  Cases 
of  this  kind  are  distinguished  by  the  following  circumstances  :  the  atrophy 
and  paralysis  rapidly  involve  the  injured  arm;  the  disease  chiefly  attacks 
the  muscles  supplied  by  certain  nerves;  there  is  diminution  or  loss  of  elec- 
tro-muscular contractility  in  the  affected  parts  ;  painful  spots  are  felt 
upon  pressure  over  the  plexus  or  certain  nerve-trunks. 

From  the  nature  of  the  disease,  to  which  we  have  referred  in  the  pre- 
vious section,  we  can  readily  comprehend  that  the  p)rof)nosis  of  progres- 
sive muscular  atrophy  must  be  unfavorable  in  the  majority  of  cases.  In 
the  beginning,  as  soon  as  the  first  signs  of  alterations  in  the  muscles  are 
manifested  in  the  dorsum  and  palm  of  the  hand,  the  patients  should  imme- 
diately abandon  all  pursuits  requiring  muscular  exertion.  In  a  case  of 
moderate  atrophy  of  the  left  thenar  eminence,  of  the  first  two  interossei 
and  of  the  lower  half  of  the  forearm,  with  diminution  of  faradic  reaction, 
the  patient  abandoned  his  trade  (weaver),  took  a  long  trip  to  the  country, 
and  made  a  recovery,  through  the  employment  of  faradization,  which  has 
persisted  for  a  year  and  a  half.  In  a  mechanic,  treated  by  Duchenne 
(Electrisation  Localisee,  2*  edit.,  Obs.  121),  a  large  portion  of  the  muscles  of 
the  left  arm  and  trunk  were  atrophied;  the  muscles  of  the  arm  recovered 
their  nutrition  and  motor  functions,  through  the  use  of  the  faradic  current. 
The  recovery  has  continued  for  ten  years,  although  the  patient  has  resumed 
his  manual  labor.  But  these  are  merely  fortunate  exceptions.  As  a 
rule,  renewed  efforts  cause  the  muscles  to  lose  the  little  which  they  have 
gained,  and  motion  and  nutrition  deteriorate  more  and  more.  In  older  or 
more  advanced  forms,  we  may  sometimes  obtain  marked  improvement,  or 
an  arrest  of  the  disease  for  a  certain  length  of  time,  especially  in  young 
and  otherwise  healthy  subjects.  In  the  large  majority  of  my  cases  there 
was  no  marked  or  lasting  improvement.  The  disease  pursues  its  course 
without  remission,  and  despite  careful  treatment  continued  for  a  num- 
ber of  months.     The  circumstances  which  are  of  most  importance  are  the 


DISEASES    OF   THE    NERVOUS    SYSTEM.  21 

intensity  of  the  central  lesions  and  the  extension  of  the  degeneration  to 
the  trophic  centres.  When  the  latter  are  not  seriously  involved,  when 
the  atrophy  of  the  muscles  is  limited  to  a  part  of  the  extremities,  the 
disease  may  be  arrested  at  a  certain  point  or  may  even  retrocede.  But 
the  situation  is  grave  when  an  hereditary  disposition  is  present,  when  the 
muscles  are  rapidly  involved,  and  when  the  muscular  atrophy  proceeds 
from  several  points  at  the  same  time.  If  the  atrophy  and  paralysis  attack 
the  respiratory  muscles,  the  diaphragm  and  pharynx,  very  serious  com- 
plications will  develop,  such  as  pulmonary  hypostasis,  bronchitis,  and 
asphyxia. 

Treatment. 

Following  Duchenne's  example,  we  may  begin  the  treatment  of  pro- 
gressive muscular  atrophy  by  means  of  the  induced  current.  It  should  be 
very  strong  in  the  beginning,  and,  when  the  functions  and  sensibility  of 
the  muscles  have  improved,  we  should  employ  weaker  currents  in  order  that 
they  may  not  be  too  exciting.  If  the  disease  is  very  extended,  it  is  diffi- 
cult to  give  all  the  muscles  sufficient  attention  and  the  full  benefit  which 
may  thus  be  derived  from  electrization.  In  treatment  with  galvanism, 
interrupted  currents  should  be  passed  from  the  vertebral  column  and 
plexuses  to  the  nerves  of  the  affected  muscles.  In  this  manner  Ave  may 
cause  the  current  to  act  upon  entire  groups  of  muscles.  The  descending 
current,  which  is  preferably  employed,  should  not  produce  too  violent 
contractions.  In  more  extended  forms  it  will  be  wise  to  alternately 
apply  the  constant  current  to  the  nerves,  and  the  induced  current  to  the 
muscles.  At  the  first  appearance  of  disorders  of  respiration  or  degluti- 
tion, we  must  employ  galvanization  or  faradization  of  the  phrenic  or 
hypoglossal  nerves. 

Remak  recommends  galvanization  of  the  fibres  of  the  sympathetic, 
which  presents  very  marked  sensibility  in  progressive  muscular  atrophy. 
But,  in  the  first  place,  our  knowledge  of  the  sympathetic  system  is  still 
involved  in  obscurity,  and  we  must  remember  that,  in  applying  an  electrode 
over  the  upper  cervical  ganglion,  the  current  will  readily  affect  the 
brachial  plexus;  furthermore,  the  sympathetic  has,  at  the  present  time, 
lost  the  importance  which  had  been  previously  attached  to  it  in  progressive 
muscular  atrophy;  finally,  I  have  employed  this  method  several  times 
without  obtaining  the  brilliant  results  which  some  neurologists  claim. 


22  CLINICAL   TEEATISE    ON 


CHAPTER  XXVI. 

NEUROSES  OF   THE  SPINAL  CORD  (SPINAL  IRRITATION,  NEURASTHENIA). 

If  we  observe  a  large  number  of  cases  of  nervous  disease,  we  not  in- 
frequently find  certain  conditions  which  cannot  be  regarded  as  true 
spinal  diseases,  and  which  do  not  enter  into  the  large  and  elastic  category 
of  hysterical  affections.  These  diseases  may  even  last  several  years, 
under  very  different  aspects,  without  giving  rise  to  the  severe  symptoms, 
the  profound  changes,  or  to  the  complications  which  are  observed  in  con- 
sequence of  changes  in  the  tissues  of  the  spinal  cord.  Nevertheless  we 
cannot  fail  to  recognize  that  medullary  symptoms  of  irritation  or  de- 
pression constitute  the  most  striking  features  of  these  mysterious  morbid 
conditions.  Without  admitting  the  theoretical  views  hitherto  enunciated 
concerning  the  disease  in  question,  we  nevertheless  think  that,  from  a 
practical  point  of  view,  it  will  be  convenient  to  retain  the  s)^mptomatic 
term  of  spinal  irritation,  in  order  to  designate  these  morbid  conditions 
whose  exact  boundaries  and  classification  still  remain  to  be  drawn.  We 
may  even  question  whether  such  changeable  and  capricious  symptoms 
will  ever  obtain  an  anatomical  basis  through  the  aid  of  post-mortem  ex- 
aminations. 

Before  entering  into  a  description  of  the  different  forms  of  spinal 
irritation,  we  may  remark  that  its  complex  symptoms  do  not  always 
appear  to  be  solely  dependent  upon  the  spinal  cord;  the  frequent  com- 
plication with  psychopathic  symptoms  indicates  that  the  cerebrum  may 
also  be  involved.  The  clinical  analysis  of  the  forms  which  are  included 
under  spinal  irritation  shows,  in  addition,  that  symptoms  either  of  depres- 
sion or  of  irritation  predominate  in  each  case.  But  we  also  meet  with 
mixed  forms  in  which  the  two  orders  of  symptoms  are  intermingled.  I 
believe,  however,  that,  from  a  practical  point  of  view,  we  may  distin- 
guish, for  the  purposes  of  study  and  treatment  of  spinal  irritation,  a  hy- 
peraesthetic  form  and  a  depressive  form  (neurasthenia  of  several  authors). 

a.  HypercBsthetic  Form  of  Spinal  Irritation. 

The  symptoms  of  irritation  predominate  in  this  type.  They  are  ob- 
served especially  in  females,  and  generally  develop  progressively.  The 
first  manifestations  of  the  disease  consist  of  frequently  recurring  mental 
uneasiness  and  a  feeling  of  malaise  in  the  back  and  limbs.  Usually  the 
patients  complain  of  distressing  rachialgia,  which  only  appears,  at  first, 
intermittently  and  after  exertion  or  fatigue,  but  soon  becomes  more 
persistent  and  intense.  The  pain  is  usually  situated  between  the  scapulas 
or  in  the  neck,  and  more  rarely  in  the  lower  part  of  the  dorsal  spine;  it 
almost  always  occupies  several  vertebrae,  and  is  less  subject  to  variations 
of  position  than  of  intensity. 

The  painful  region  presents  acute  sensibility  (tenderness  of  the  spine) 


DISEASES    OF   THE    NERVOUS    SYSTEM.  23 

even  to  slight  mechanical,  electrical,  or  thermic  irritations  (the  contact 
of  a  sponge  dipped  in  hot  water).  The  spinous  processes,  and  a  por- 
tion of  the  transverse  processes,  cannot  tolerate  the  slightest  pressure, 
and  when  the  hyperjesthesia  is  also  present  in  the  skin  which  covers 
them,  the  weight  of  the  clothes  or  leaning  against  a  piece  of  furniture, 
etc.,  produces  intolerable  pain.  The  dorsal  pain  also  increases,  according 
to  the  statements  of  the  patients,  during  exertion,  flexion  of  the  trunk, 
the  vertical  position,  ascending  a  flight  of  stairs,  etc.  The  vertebral 
column  is  then  hyperassthetic  and  painful  throughout  a  large  part  of  its 
extent,  and  forms,  in  some  sort,  a  centre,  from  which  the  pains  radiate 
towards  different  parts  of  the  body. 

According  to  the  height  at  which  these  phenomena  of  irritation  are 
situated,  certain  symptoms  will  assume  more  importance.  When  the 
disease  chiefly  involves  the  cervical  region,  the  spinal  pain  and  sensitive- 
ness are  especially  marked  in  the  neck.  We  may  then  observe  other 
concomitant  symptoms  :  cephalalgia,  vertigo,  insomnia,  nausea,  vomiting, 
cervico-oceipital  or  cervico-brachial  neuralgia,  pains  radiating  into  the 
nerves  of  the  face.  We  also  notice  dyspnoea,  palpitation  of  the  heart, 
and  hiccough;  the  upper  limbs  feel  heavy  and  sore. 

If  the  dorsal  region  is  affected,  we  often  find,  in  addition  to  the  verte- 
bral pains  in  this  region,  brachialgia,  intercostal  neuralgia,  gastralgia,  and 
dyspepsia.  Finally,  if  the  affection  occupies  the  lower  dorsal  and  the 
lumbar  region,  lumbar  neuralgias,  pains  along  the  crural  and  sciatic 
nerves,  neuralgia  of  the  abdominal  walls,  colic,  ovaralgia,  and  vesical 
spasm  are  especially  noticeable.  In  addition,  the  legs  are  usually  weak 
and  the  feet  are  more  often  cold  than  warm. 

The  pains  in  the  different  portions  of  the  body,  to  which  we  have  re- 
ferred, are  either  fixed  or  wandering  and  intermittent;  they  often  follow 
the  course  of  the  nerves.  They  may  be  accompanied  by  formication, 
numbness  in  the  limbs,  sensations  of  burning,  heat,  and,  sometimes,  of 
cold.  Generally,  we  do  not  notice  true  ansesthesias  in  these  forms  of 
spinal  irritation. 

More  or  less  serious  motor  disturba?ices  often  occur.  These  consist, 
in  the  slight  forms,  of  muscular  weakness,  diminished  resistance  to 
fatigue,  and  partial  muscular  spasms  in  the  limbs. 

In  more  severe  forms  the  pains  rapidly  increase  in  violence,  and  may 
deprive  the  patients  of  the  use  of  their  limbs.  They  can  only  walk  a 
few  steps  with  marked  effort,  tremor,  and  vertigo.  They  cannot  even 
use  their  hands  in  the  simplest  occupations,  to  perform  any  manual  labor, 
to  write,  play  the  piano,  etc.,  all  muscular  action  producing  pain  in  the 
back  and  limbs.  The  patient  asks  to  be  left  quiet  in  the  dorsal  decubitus 
and  in  absolute  muscular  inaction.  Nevertheless  true  paralyses  do  not 
occur. 

The  mejital  faculties  are  also  changed,  and  present  the  symptoms  of 
abnormal  irritability.  There  is  a  condition  of  intellectual  malaise,  and  a 
feeling  of  constriction  in  the  head;  the  patient  cannot  speak  or  read  a 
long  time,  as  he  soon  becomes  tired;  the  face  readily  reddens  or  pales. 
Insomnia  usually  occurs.  These  extremely  sensitive  individuals  react 
very  strongly  to  the  impressions  of  the  outer  world.  Slight  functional 
disorders  are  sufficient  to  produce  strong  febrile  movement  and  cephalic 
symptoms,  followed  by  exhaustion. 

Spinal  irritation  (the  hyperfesthetic  form)  nearly  always  pursues  a 
chronic  course.  The  phenomena  of  irritation  may  disappear  after  having 
lasted  several  weeks  or  months,  but  exacerbations  and  relapses  are  fre- 


24  CLIlSnCAL    TREATISE    ON 

quent;  they  occur  from  slight  causes,  and  often  without  any  known  provo- 
cation. A  permanent  improvement  of  the  irritative  symptoms  has  a 
favorable  effect  upon  the  general  condition,  since  the  patients,  hitherto 
confined  to  the  dorsal  decubitis,  may  again  rise;  their  movements  increase 
in  activity  and  duration,  and  digestion,  sleep,  and  the  mental  condition 
improve. 

The  improvement  may  persist  for  a  longer  or  shorter  period.  If  it 
continues  for  a  certain  length  of  time,  we  may  hope  for  recovery,  under 
favorable  conditions,  and  if  the  patients  are  properly  treated.  But  fre- 
quently they  retain  some  annoying  spinal  symptoms  during  their  whole 
life.  Sometimes  the  hypergesthetic  form  passes  into  the  depressive  form, 
which  we  shall  describe  at  a  later  period. 

From  an  etiological  point  of  view,  we  may  remark  that  spinal  irritation 
is  much  more  frequent  in  women,  especially  from  the  ages  of  ten  to  thirty 
years.  An  hereditary  predisposition  to  nervous  affections  often  plays  an 
important  part  as  a  pathogenic  factor.  Among  the  exciting  causes  we 
may  mention  all  influences  which  produce  stimulation  or  depression  of  the 
nervous  system.  Lively  emotions,  mental  distress,  unrequited  love,  ex- 
cessive stimulation  of  sexual  desires,  over-exertion  and  night-work,  con- 
stitute some  of  the  most  frequent  causes.  Morbid  conditions  of  the  blood 
(antemia  and  hydraemia),  contagious  and  miasmatic  affections  (acute  ex- 
anthemata, typhoid  and  intermittent  fever,  etc.),  haemorrhages,  seminal 
losses,  and  finally,  traumatic  and  rheumatic  affections,  may  also  give  rise 
to  spinal  irritation. 

All  that  can  be  said  at  present,  with  regard  to  the  nature  of  sjnnal  irri- 
tation, is  that  it  consists  in  an  abnormal  irritability  of  the  nervous  cen- 
tres, usually  hereditär}^,  but  also  acquired  under  the  influence  of  different 
diseases,  of  anaemia,  or  of  prolonged  mental  excitement. 

The  rapid  exhaustion  and  the  excessive  irritability  of  the  vaso-motor 
apparatus  contained  in  the  cord  plays  a  considerable  part  in  the  symptoms 
of  spinal  irritation.  We  may,  at  least,  suppose  that  the  exciting  and  de- 
bilitating influences  to  which  we  have  referred  produce  an  exaggerated 
shock  of  the  vasomotor  centres,  giving  rise  to  relaxation  of  the  vessels 
and  hyperemia;  if  these  centres  recover  with  difficulty,  the  vessels,  on 
their  part,  will  occupy  a  long  time  before  their  normal  tonus  is  restored. 
In  other  forms  the  extreme  mental  excitement  gives  rise  to  contractions 
of  the  vessels  through  irritation  of  the  vasomotor  centres;  if  this  vascu- 
lar spasm  is  often  repeated,  a  rebellious  and  long-continued  anaemia  will 
result. 

The  diagnosis  of  spinal  irritation  sometimes  meets  with  great  difficul- 
ties, especially  in  the  initial  forms.  But  after  watching  the  case  for  some 
time,  we  will  observe  the  vertebral  pain  with  circumscribed  hyperaesthesia, 
the  excentric  pains,  the  irritability  of  the  sensorium,  the  rapid  exhaustion 
of  the  motor  energy,  the  absence  of  manifest  paralysis  and  anaesthesia, 
the  variability  of  the  coexisting  nervous  phenomena,  and  the  slight  grav- 
ity of  the  objective  signs.  The  diagnosis  may  be  made  from  this  ensem- 
ble of  symptoms,  when  we  are  able,  at  the  same  time,  to  exclude  all  other 
spinal  lesions  with  analogous  manifestations.  The  differentiation  from 
spondylitis  and  vertebral  caries,  which  are  also  more  frequent  in  young 
subjects,  has  been  established  in  the  chapters  relating  to  these  affections. 
Spinal  meningitis  is  characterized,  in  the  beginning,  by  elevation  of  tem- 
perature and  frequency  of  the  pulse,  by  violent  and  diffused  dorsal  pain, 
by  tonic  spasms  of  the  muscles  of  the  neck  and  back  which  render  all 
movements  painful,  and  by  the  atrophic  paralyses  and  contractures  of  the 


DISEASES    OF    THE    NERVOUS    SYSTEM.  25 

limbs  with  loss  of  farado-muscular  contractility  which  follow  this  dis- 
ease. 

3IyelUis  is  distinguished  from  spinal  irritation  by  the  early  appearance 
of  evident  anaesthesia  and  paralysis;  by  the  correlation  of  the  disturb- 
ances of  sensation  with  the  distribution  of  the  medullary  sensory  nerves; 
by  the  existence  of  girdling  pains,  and  often  of  spasms  and  contractures. 
We  also  find  other  important  diagnostic  signs  in  myelitis,  viz.:  abolition 
of  the  action  of  the  sphincters;  tenderness  and  pain  upon  pressure  of  the 
vertebral  column  usually  less  pronounced;  no  abnormal  psychical  irritabil- 
ity or  fluctuation  in  the  symptoms,  such  as  is  observed  in  spinal  irritation. 

The  latter  coincides  with  hysteria  in  the  extreme  susceptibility  of 
the  nervous  system;  but  we  do  not  find  those  profound  changes  in  the 
psychical  sphere,  nor  the  convulsive  or  paralytic  disorders  of  motion  or 
sensation,  with  anomalies  in  the  electrical  reactions,  nor  the  disorders  of 
vegetative  life,  which  belong  to  hysteria.  Apart  from  these  important 
symptoms,  the  other  manifestations  of  nervousness  in  spinal  irritation  do 
not  offer  that  tenacity  and  periodicity,  nor  the  prognostic  and  thera- 
peutic difficulties,  which  sometimes  complicate  the  history  of  hysteria. 

The  treatment  of  spinal  irritation  should  consist  in  removing,  as  far  as 
possible,  the  pathogenic  causes  to  which  we  have  referred,  and  in  improv- 
ing the  tone  of  the  nervous  system.  The  best  stimulant  and  tonic  ef- 
fects are  obtained  by  ahundant  nutriment,  with  light  wines  or  beer;  we 
may  also  administer  small  doses  of  iron  and  quinine.  A  long  sojourn  in 
the  pure  air  of  the  country,  preferably  upon  high  mountains  and  in  the 
midst  of  forests,  usually  exercises  a  salutary  influence  upon  the  nervous 
functions.  But,  in  these  conditions,  we  must  not  advise  the  patients  to 
indulge  in  too  much  exercise;  they  should,  on  the  contrary,  rest  often  and 
long. 

The  antiphlogistic  and  derivative  measures  of  former  therapeutics  are 
rarely  employed  at  the  present  time.  In  robust  and  full-blooded  subjects 
we  may  derive  benefit  from  scarifications  along  the  vertebral  column,  and 
from  the  application  of  leeches  to  the  vulva  or  anus.  The  moxa  and  actual 
cautery  are  no  longer  employed.  The  cautious  employment  of  blisters 
and  tartar  emetic  ointment  may  be  sometimes  recommended. 

In  order  to  quiet  the  distressing  dorsal  pains  and  the  burning  sensa- 
tions in  the  legs  and  soles  of  the  feet,  the  patient  should  wear  upon  the 
back  a  tube  of  india-rubber,  filled  with  moderately  cold  water;  the  tube  is 
kept  in  place  by  a  bandage  applied  transversely  in  such  a  manner  as  not 
to  prove  annoying,  and,  if  the  vertebral  sensibility  is  very  acute,  a  layer 
of  wadding  may  be  interposed. 

Good  effects  are  sometimes  prodiiced  by  passing  the  ascending  constant 
galvanic  current  along  the  spinal  column  (exposing  the  painful  points  to 
the  action  of  the  cathode).  The  current  should  be  of  moderate  intensity, 
and  the  sitting  of  short  duration.  Nux  vomica  and  strychnine  are  recom- 
mended by  several  authors.  Finally,  hydrotherapeutics  may  also  prove 
successful  in  spinal  irritation.  At  first,  affusions  should  be  made  to  the 
back  (with  water  which  is  rendered  cooler  from  day  to  day)  in  a  half-bath 
of  24° -20°  C. ;  later,  we  may  employ  wet  packs,  continued  until  the 
warmth  of  the  body  has  returned,  followed  by  lotions  and  irrigations  of 
the  vertebral  column,  while  the  patient  is  in  a  half-bath  of  moderate 
temperature.  We  may  also  recommend  the  patient  to  wear  a  moist 
cloth  upon  the  back,  covered  with  a  dry  one,  and  renewed  two  or  three 
times  daily.  Cold  applications  and  cold  douches  should  not  be  employed; 
warm  douches  to  the  dorsal  spine  often  prove  advantageous. 


26  CLINICAL    TEEATISE    ON 


b.   Depressed  Form  of  Spinal  Irritation  {Neurasthenia). 

In  this  variety  of  spinal  irritation,  the  most  striking  characteristics  are 
represented  by  symptoms  of  spinal  depression.  We  refer  chiefly  to  this 
neurosis  when  we  speak  of  "nervous  weakness,"  and  Beard,  Rockwell, 
and  Erb  have  proposed  for  it  the  term  neurasthenia.  Leyden  has  recently 
described  cases  of  this  kind  under  the  title  of  "  spinal  irritation,  following 
seminal  losses." 

Dorsal  jya in  is  almost  always  present  in  this  form,  as  in  the  preceding, 
but  it  is  neither  so  acute  nor  so  persistent.  The  pain  is  situated  some- 
times in  the  lumbar,  sometimes  in  the  upper  dorsal  portion  of  the  verte- 
bral column.  Some  of  the  spinous  processes  are  moderately  tender  on 
pressure,  and  the  patient  experiences  in  them  a  sensation  of  burning, 
compression,  or  tension.  The  dorsal  pain  increases  after  fatigue  and  ex- 
ertion, after  extensive  movements  of  the  vertebral  column,  and  after  ex- 
posure and  excesses.  We  often  observe,  as  coexisting  symptoms,  a  feel- 
ing of  oppression,  dyspncea,  palpitation  of  the  heart,  and  constriction  of 
the  head.  Certain  patients  complain  of  annoying  numbness  or  formica- 
tion in  the  coverings  of  the  cranium.  But  the  phenomena  which  espe- 
cially distress  the  patients  are  weakness  in  2^Grforraing  movements  and 
rapid  exhaustion.  After  a  very  short  walk,  motion  becomes  difficult,  and 
the  knees  and  lumbar  region  are  the  seat  of  a  peculiar  sensation  of  re- 
laxation. The  patients  cannot  stand,  for  any  length  of  time,  without  sup- 
porting themselves  or  bending  one  of  the  knees.  They  are  also  almost 
alwavs  unable  to  stand  upon  one  foot  with  the  eyes  closed,  although  they 
are  able  to  do  this  with  the  eyes  open.  The  upper  limbs  also  take  part 
in  this  exhaustion,  although  to  a  less  degree. 

Forced  movements  soon  produce  a  sensation  of  heaviness  in  the  legs, 
with  muscular  pains.  A  small  quantity  of  wine,  taken  during  repose, 
often  produces  strengthening  and  tonic  effects.  Other  important  disor- 
ders also  appear  on  the  part  of  the  genital  functions.  In  general  the  pa- 
tients are  easily  excitable,  but  the  erections  and  virile  power  are  deficient; 
ejaculation  of  semen  is  often  premature,  and  followed  by  distressing  sen- 
sations in  the  back  and  legs.  When  the  mind  is  occupied  with  erotic 
thoughts,  and  even  after  defecation  or  micturition,  some  drops  of  prostatic 
fluid  (almost  always  without  admixture  with  spermatozoids)  frequently 
appear  at  the  meatus.  True  spermatorrhoea  only  occurs  at  great  inter- 
vals; chronic  pollutions,  on  the  other  hand,  are  frequent,  and,  when  they 
follow  one  another  in  rapid  succession,  they  greatly  aggravate  the  man- 
ifestations of  the  disease.  In  the  majority  of  patients,  the  urethral  canal 
presents,  especially  in  the  prostatic  portion,  an  acute  sensitiveness,  even 
when  a  sound  of  small  calibre  (19  or  20,  Charriere)  can  be  introduced 
without  difficulty.  This  operation  may  produce  intense  local  pain,  a 
burning  sensation,  and  even  convulsions.  The  functions  of  the  bladder 
are  usually  normal;  sometimes,  however,  a  burning  sensation  is  experienced 
after  the  passage  of  the  last  drops  of  urine. 

^\xQ,  psychical  facidties  may  be  more  or  less  affected.  The  intelligence 
is  preserved,  but  memory  and  judgment  are  defective.  The  capacity  for 
intellectual  labor  is  markedly  diminished,  and  the  patients  are  deficient  in 
will  power.  A  hypochondriacal  disposition  is  especially  noticeable,  some- 
times with  a  tendency  to  weep,  and  with  a  pecviliar  dread  of  locomotor 
ataxia.  The  sleep  is  uneasy  and  frequently  interrupted,  and  the  patients 
complain  of  prostration,  and  dulness  upon   rising  from  bed.     Numbness 


DISEASES    OF    THE    NERVOUS    SYSTEM.  27 

and  formication  in  the  feet  are  frequently  experienced.  But  the  most 
disagreeable  sensation  of  which  the  patients  complain  is  coldness  of  the 
hands  and  feet,  which  only  disappears  slowly  after  the  patient  has  become 
warm  in  bed;  on  the  other  hand,  when  covered  too  warmly,  cerebral  con- 
gestions readily  occur. 

The  nutritive  functions  are  almost  always  poorly  accomplished.  The 
patients  complain  of  flatulence,  belching,  diminution  of  appetite,  and  con- 
stipation; the  tongue  is  coated,  and  the  patients  are  emaciated  and  anae- 
mic; dilatation  of  the  stomach  is  observed  in  rare  instances. 

Objective  examination  discloses  no  disorders  of  motion  or  sensation 
corresponding  to  the  numerous  subjective  disturbances  of  which  the 
patients  complain.  The  most  striking  phenomenon  in  the  disease  is  the 
want  of  persistence  in  the  muscular  activity.  In  the  majority  of  cases 
the  affection  develops  progressively  and  almost  insensibly.  It  only  reaches 
its  culmination  after  the  lapse  of  several  months  or  even  of  several  years. 
Nevertheless,  in  exceptional  instances,  the  symptoms  may  appear  more 
rapidly  under  the  influence  of  emotions,  fatigue,  excesses,  or  repeated  sem- 
inal losses.  Recent  and  slight  cases  may  recover  after  a  few  weeks.  In 
old,  chronic  forms  (lasting  several  years)  the  condition  of  the  patient  may 
vary  a  great  deal;  but  we  cannot  hope  for  persistent  improvement  except 
after  the  lapse  of  months  or  years,  even  under  the  most  appropriate  treat- 
ment and  habits  of  life.  Relapses  are  not  infrequent,  and  are  often  pro- 
duced by  slight  causes;  the  patient  is  sad  and  melancholy,  and  flees  the 
society  of  his  fellows  more  and  more.  Under  unfavorable  conditions,  ex- 
cessive exertion,  fatigue,  and  violent  exposure  may  implant  the  first  germs 
of  organic  lesions  of  the  spinal  cord. 

The  male  sex  furnishes  a  much  larger  proportion  of  cases  of  the  de- 
pressed form  of  spinal  irritation  than  the  female  sex,  contrary  to  what 
occurs  in  the  hyperaesthetic  variety.  The  disease  develops,  with  the 
greatest  frequency,  at  puberty  and  during  middle  age.  The  influence  of 
heredity  is  manifested  by  the  coexistence  of  other  neuroses  in  the  same 
family.  The  disease  is  much  more  frequent  among  the  better  classes  of 
society  than  among  the  poor. 

Excessive  excitement  of  the  sexual  functions  constitute  the  most  fre- 
quent and  positive  cause  of  this  affection.  This  is  especially  true  of 
masturbation,  which  young  boys  frequently  continue  in  youth,  and 
which,  being  then  combined  with  greater  hardships,  develops  spinal  irri- 
tation. Onanism  may  lead  to  the  same  results  in  young  girls.  Sexual 
excesses  also  act  in  the  same  manner,  especially  those  which  are  com- 
mitted by  weak  young  people  at  the  age  of  puberty  or  shortly  after 
marriage;  this  also  occurs  from  prolonged  and  unsatisfied  sexual  excite- 
ment. 

Finally,  intellectual  efforts,  insomnia,  miserable  habits  of  life,  and  pro- 
longed emotional  disturbance,  may,  in  predisposed  subjects,  lead  to  the 
outbreak  of  this  spinal  neurosis. 

We  can  merely  form  hypotheses  as  to  the  nature  of  the  disease.  The 
prolonged  action  of  the  causes  which  we  have  mentioned,  acting  especially 
during  youth,  may  produce  excessive  irritability  of  the  medullary  and 
vasomotor  centres.  This  condition,  becoming  chronic,  causes  rapid  ex- 
haustion of  the  spinal  nervous  influx,  and  a  slowing  of  the  current  of 
blood  with  passive  hypersemia,  or  a  lowering  of  the  temperature  in  the 
peripheral  parts.  The  lumbar  pains,  the  weakness  of  the  legs,  the  circu- 
latory disturbances  in  the  same  regions,  and  the  disorders  of  the  sexual 
functions,  indicate  anaemia  of  the  lumbar  portion  of  the  cord,  and  the 


28    CLINICAL    TREATISE    ON    DISEASES    OF    THE    NERVOUS    SYSTEM. 

chronic  character  of  this  lesion  accounts  for  the  tenacity  of  the  symptoms 
of  depression  depending  upon  it. 

In  forming  a  diagnosis,  we  must  carefully  examine  the  patient  and 
take  into  consideration  the  previous  history  of  the  disease.  A  prolonged 
observation  will  often  be  necessary  in  order  to  exclude  the  onset  of  other 
spinal  diseases. 

Incipient  ataxia,  which  is  most  readily  mistaken  for  this  variety  of 
spinal  irritation,  is  distinguished  by  the  characteristic  lancinating  pains 
and  sciatica,  by  the  early  disorders  of  sensation,  the  girdling  pains,  the 
pupillary  anomalies,  the  pareses  of  ocular  muscles,  the  oscillations  which 
the  patient  experiences  when  he  wishes  to  turn  around  with  the  eyes 
closed,  and  by  the  exaggeration  of  galvanic  excitability.  Incipient 
myelitis  is  characterized  by  the  rapid  appearance  of  vague  neuralgia, 
manifest  paresis  and  paralysis  of  the  lower  limbs,  the  prompt  abolition  of 
the  various  forms  of  sensibility  in  the  same  regions,  the  stiffness  and 
difficulty  of  movements  and  the  feebleness  of  the  sphincters.  The  dis- 
tinctive signs  of  commencing  vertebral  caries  have  been  described  in  a 
preceding  chapter.  Finally,  intense  dorsal  pain,  acute  sensitiveness  of 
the  vertebral  column,  neuralgia  and  pain  during  motion,  are  peculiar  to 
the  hypera?sthetic  form  of  spinal  irritation;  while,  in  the  depressed  form, 
the  predominant  symptoms  consist  of  the  exhaustion  of  the  motor  energy, 
the  sexual  weakness,  the  seminal  losses,  the  psychical  changes,  etc. 

The  treatment  must  consist  at  first  of  prolonged  rest  and  isolation  of 
the  patient;  he  should  abstain  from  emotional  and  sexual  excitement  and 
from  intellectual  labor.  Benefit  is  derived  from  a  trip  to  the  country, 
either  among  the  mountains  or  at  the  sea-shore,  avoiding,  at  the  same 
time,  all  fatigue  and  long  walks.  The  diet  should  be  substantial  but 
easily  digested,  and  a  little  wine  or  beer  may  be  taken  with  the  meals. 
Small  doses  of  quinine  or  nux  vomica,  and  light  ferruginous  preparations 
or  waters  often  prove  advantageous. 

A  trip  to  a  chalybeate  spring  is  indicated  in  anfpmic,  emaciated  patients, 
who  are  very  sensitive  to  cold  or  who  suffer  from  painful  twinges  in  the 
muscles.  At  a  later  period,  when  recovery  has  made  some  progress, 
moderately  cool  lotions  may  serve  as  a  transition  to  hydr other apeutic 
treatment.  We  may  begin  by  making  irrigations  to  the  back  in  a  half- 
bath  of  moderate  temperature,  which  is  gradually  lowered;  afterwards  we 
may  employ  lotions  with  a  wet  cloth.  We  should  avoid  douches,  full 
cold  baths,  etc.     Sea-baths  are  also  useful  during  convalescence. 

Finally,  electricity  gives  some  good  results.  The  moderate  ascending 
continuous  current  should  be  passed  through  the  dorsal  spine,  and  may 
also  be  applied  to  the  legs;  faradic  currents  of  great  tension  should  not 
be  employed. 


CLASS     IV. 


HYSTERIA  AND  ITS  CONCOMITANT  NERVOUS  DISORDERS. 


CHAPTER  XXVII. 

HYSTERIA. 


Hysteria,  must  be  regarded  as  one  of  the  oldest  products  of  civiliza- 
tion. It  was  described  with  great  clearness  by  Herodotus  and  Hippo- 
crates, and  in  the  writings  of  Plato,  Certain  hysterical  phenomena  have 
played  a  sad  part  at  other  periods,  as  in  the  terrible  history  of  sorcery 
which  darkened  the  early  period  of  Christianity.  Hysterical  patients 
affected  with  convulsions  or  catalepsy,  and  others  who  were  delirious  or 
ecstatic,  were  accused  of  intercourse  with  the  devil,  and  many  of  these 
unhappy  creatures  died  at  the  stake,  as  being  possessed  of  a  demon. 
Hysteria,  combined  with  a  condition  of  religious  exaltation,  also  played  a 
considerable  part  in  the  convulsive  epidemics  of  the  last  century. 


Symptomatology. 

The  numerous  peculiarities  of  this  morbid  process  do  not  permit  a 
description  of  its  symptoms  in  a  strict  chronological  order.  We  shall 
therefore  study  separately  the  disorders  of  sensation  and  motion,  of  the 
sensorial  functions  and  of  vegetative  life. 

The  sensory  disturhances  are  characterized  by  hyperaesthesia,  anaes- 
thesia,, and  neuralgia. 

Hypsrcesthesia. — The  skin  is  frequently  the  site  of  spontaneous  pains; 
the  lightest  touch  will  also  produce  painful  sensations.  In  a  more  severe 
form  the  hands  cannot  grasp  any  object,  and  the  feet  cannot  tolerate  the 
contact  with  the  ground. 

The  hyperaasthesia  rarely  extends  over  the  entire  surface  of  the  body.  In  a  quarter 
of  the  cases  of  hyperaesthesia,  observed  by  Briquet  (Traite  de  I'Hysterie.  Paris,  1859), 
it  extended  over  one-half  the  body  (usually  the  left),  and  was  limited  by  the  median 
line. 

Upon  the  scalp,  the  hyperassthesia  is  manifested  chiefly  at  the  occi- 
put; it  also  occurs  upon  the  back,  thorax,  and  abdominal  walls.  Larger 
or  smaller  patches  of  hyperaesthesia  are  also  found  upon  the  limbs,  and 
may  readily  pass  unnoticed.     Brodle  first  called  attention  to  hypercßsthesia 


30  CLINICAL    TREATISE    ON 

of  the  joints^  usually  involving  the  hip  and  knee.  "When  it  is  accom- 
panied by  swelling  and  oedema  of  the  neighboring  parts,  it  may  simulate 
arthritis.  The  real  nature  of  these  phenomena  is  rendered  evident  by 
the  following  circumstances:  normal  position  of  the  parts  (except  when 
secondary  contracture  of  the  muscles  has  developed);  passive  motion 
preserved;  peculiar  sensibility  of  the  skin  to  pinching,  even  in  parts 
which  are  at  a  distance  from  the  joint;  no  appreciable  change  in  the 
nutrition  of  the  muscles,  even  after  the  disease  has  lasted  a  long  time; 
alteration  in  the  affection  at  each  menstrual  epoch  (Stannius). 

In  consequence  of  muscular  hypermsthesia,  which  is  frequent  in  hys- 
terical patients,  superficial  pressure,  weak  faradic  excitation,  or  even  the 
slightest  movement,  will  produce  intolerable  pain,  and  the  patients  are 
condemned  to  absolute  rest. 

IIyper(jesthesia  of  the  special  senses  is  a  rare  but  very  distressing 
symptom.  The  eye  becomes  extremely  sensitive  to  light,  the  ear  to  the 
slightest  noise,  the  nose  to  certain  odors. 

The  hyperjBsthesia  usually  occurs  in  consequence  of  emotional  excite- 
ment, after  an  hysterical  seizure  ;  it  may  be  limited  to  one-half  the  body, 
while  the  other  half  is  anaesthetic.  Finally,  hyperresthesia  constitutes  a 
favorable  sign  in  hysterical  paralyses,  which  were  primarily  complicated 
with  anaesthesia. 

We  may  here  mention  the  abnormal  increase  of  reflex  excitabiHtp  sometimes  pres- 
ent in  hysteria.  Stilling  and  Tuerck  have  noticed  that  pressure  upon  the  spinous  pro- 
cesses may  give  rise  to  convulsions.  In  other  cases,  deep  pressure  over  the  ovary  or 
epigastric  region  (^Schuetzenberger)  produces  analogous  hysterical  symptoms. 

Ancesthesia. — Beau  distinguishes  two  forms  of  annesthesia:  anaesthesia 
to  contact  and  to  pain  (analgesia).  The  latter  variety  also  occurs  in 
hypochondria,  cerebral  apoplexy,  spinal  diseases,  lead-poisoning,  and  in 
the  first  stage  of  ether  and  chloroform  narcosis. 

Hysterical  anaesthesia  rarely  involves  the  whole  integument.  Hemi- 
plegia of  sensation  occurs  more  frequently,  and  almost  always  upon  the 
left  side.  This  latter  fact  is  owing,  according  to  Briquet,  to  the  greater 
sensibility  of  the  skin  to  stimulation,  and  to  the  greater  delicacy  of  the 
tactile  functions,  upon  the  left  half  of  the  body.  The  analgesia  usually 
occupies  the  same  limits  as  the  annesthesia;  in  exploration  we  may  em- 
ploy the  point  of  a  pin  or  the  electric  brush.  According  to  Charcot's 
recent  observations  (loc.  cit.),  hemiannesthesia,  together  with  paresis  and 
contracture  of  the  limbs,  appears  to  be  connected  with  a  bilateral  or 
unilateral  ovaralgia,  and  frequently  changes  its  situation  in  the  same 
way  that  the  latter  does.  The  anaesthetic  region  is  sometimes  inter- 
spersed with  small  spots  in  which  sensibility  remains  intact.  As  a  rule, 
the  an;esthetic  parts  have  also  lost  their  sensibility  to  temperature  and 
their  reflex  excitability. 

Before  continuing  the  study  of  hysterical  disorders  of  innervation,  I 
wish  to  relate  an  observation,  which  is  interesting  from  several  points  of 
view,  and  which  I  have  published  in  detail  in  the  Wien.  Med.  Zeitung, 
23,  24,  1871: 

A  girl,  twenty-three  years  old,  whom  I  had  previously  treated  for  hysteria  and 
catalepsy,  suffered  a  relapse  in  consequence  of  a  violent  blow  upon  the  left  breast. 
She  complained  of  obstinate  hiccough,  alternating  vs^ith  epileptiform  attacks.  The 
latter  were  preceded  bj'  a  subjective  sensation  of  cold  and  discoloration  of  the  hands 
and  tips  of  the  fingers.  The  hands  became  very  pale,  the  tips  of  the  fingers  and  nails 
of  a  deep  blue  ;  the  patient  experienced  a  disagreeable  sensation  of  cold  in  the  Jmnds,  and 


DISEASES    OF    THE    NERVOUS    SYSTEM.  31 

their  temperature,  which  was  33.4°  C.  t?i  tJie  normal  condition,  sunk  to  30.6°  C,  and  the 
pulse  dropped  from  72  to  65  or  66.  After  the  termination  of  the  hystero-epileptic  at- 
tack, the  temperature  of  the  hands  again  ascended  to  about  35.6",  the  warmth  re- 
turned, the  fingers  and  nails  became  very  red,  and  were  the  seat  of  an  abundant  per- 
spiration ;  the  pulse  increased  to  84  or  88. 

During  a  few  hours  preceding  the  attack,  the  patient  suffered  from  hyperjesthesia 
of  the  skin  in  various  parts  of  the  trunk ;  the  muscles  were  also  hyperaisthetic  to 
pressure  and  to  the  contact  of  the  bed,  so  that  the  patient  was  frequently  obliged  to 
change  her  position.  Marked  elevation  of  temperature  was  observed  upon  the  hi/pei-ces- 
thetic  side  of  the  body. 

When  the  pallor  and  cyanosis  of  the  hand  became  manifest,  the  hyperagsthesia  di- 
minished, and  gave  place  to  anaesthesia  of  the  hands,  with  a  sensation  of  numbness  in 
the  fingers  and  toes.     These  signs  infallibly  indicated  the  approach  of  an  attack. 

Towards  the  close  of  the  attack,  if  the  fingers  or  hand  were  touched,  thei/  were 
drawn  away  by  a  reflex  movement,  although  consciousness  id((S  still  abolished,  and  thepu- 
pils  were  insensible  to  light.  This  condition  having  lasted  about  three  months,  an  at- 
tack of  fever  suddenly  developed,  which  quickly  yielded  to  large  doses  of  quinine. 
The  menses  then  reappeared,  and  the  hiccough,  vomiting,  and  epileptiform  attacks 
suddenly  ceased. 

It  is  evident  that,  in  this  case,  the  attacks  were  accompanied  by  man- 
ifest symptoms  of  spasmodic  contraction,  followed  by  dilatation  of  the 
vessels,  which  will  justify  us  in  the  belief  that  the  epileptiform  attacks 
were  caused  by  an  extension  of  the  spasmodic  phenomena  to  the  cerebral 
arteries.  Analogous  disorders  of  vasomotor  innervation  probably  caused 
the  periodical  return  of  the  hypera?sthesia,  since  the  latter  always  co-ex- 
isted with  a  palpable  elevation  of  temperature  upon  the  affected  side,  and 
disappeared  as  soon  as  an.nesthesia  developed,  with  a  fall  in  the  tempera- 
ture, pallor  of  the  skin,  and  partial  cyanosis. 

Vascular  dilatation  and  rise  of  temperature  are  due,  according  to  the 
doctrines  hitherto  admitted,  to  paralysis  of  the  vaso-motor  nerves.  Ac- 
cording to  Goltz's  experiments  (Pflüg.  Arch.,  9.  Bd.,  1874),  on  the  other 
hand,  these  phenomena  are  due  to  exaggerated  function  of  the  vaso-dila- 
tor  nerves,  which  are  innervated  from  the  spinal  centre.  Upon  enclosing 
the  sympathetic  or  sciatic  nerves  in  spirals,  formed  of  copper  and  platinum 
wire,  O.  Weber  (Centralbl.,  10,  1864)  observed  narrowing  of  the  vessels, 
lowering  of  the  temperature,  and  pallor  of  the  integument,  in  the  regions 
corresponding  to  these  nerves.  These  phenomena  persisted  for  several 
weeks,  and  were  preceded  by  hyperfesthesia  and  often  by  spasmodic  con- 
vulsions; nevertheless,  when  the  experiment  was  carefully  performed,  no 
nutritive  or  inflammatory  disorders  were  produced. 

When  the  antesthesia  is  more  profound  and  extended,  the  muscular 
tissue  becomes  involved  in  its  turn,  the  muscular  power  diminishing  and 
the  electro-muscular  and  cutaneous  sensibility  disappearing.  The  various 
mucous  membranes  may  also  be  involved.  Anjesthesia  of  the  nasal  mu- 
cous membrane  causes  a?<os»j«a/  complete  or  incomplete  anmsthesia  of 
taste  will  develop,  according  as  the  buccal  cavity  and  tongue  have  lost 
their  sensibility  to  contact  and  pain  throughout  their  whole  extent,  or 
only  upon  one-half.  If  a  morsel  is  placed  in  the  mouth,  while  the  eyes 
are  closed,  and  if  the  fingers  are  anfesthetic  at  the  same  time,  the  patients 
will  not  perceive  the  presence  of  anything  in  the  mouth  except  by  looking 
in  a  mirror,  and  only  then  will  movements  of  deglutition  commence. 

The  abolition  of  sensation  may  also  involve  the   larger  and  smaller 

joints  of  the  limbs  and  trunk  as  well  as  the  bones.     In  certain  cases  I 

have  observed  lively  resistance  to  passive  movements,  without  knowledge 

or  intention  on  the  part  of  the  patients  (reflex  contractions  of  the  antag- 

-onistic  muscles).     When  the  ansesthesia  is  very  marked,  it  also  involves 


32  CLIiaCAL    TREATISE    ON 

tJie  nerves  ;  they  will  not  respond  to  energetic  pressure,  or  to  strong  gal- 
vanic or  faradic  currents. 

Finally,  sight  and  hearing  may  also  become  anaesthetic.  In  the  first 
case,  sio"ht  is  confused,  and  the  eyes  soon  become  tired  when  the  patient 
fixes  them  upon  her  work;  anaesthesia  of  the  retina,  amblyopia  or  amau- 
rosis are  very  rare;  the  latter  is  always  associated  with  hysterical  disorders 
of  sensation  and  motion.  After  a  certain  length  of  time  it  subsides  as 
suddenly  as  it  has  appeared.  Hirschberg,  Bouchut,  and  Galezowski  have 
observed  hyperaemia,  and  even  opaque  exudation  and  discoloration  of  the 
papilla,  with  partial  dilatation  of  the  retinal  vessels,  in  these  cases  of  hemi- 
opia  and  chromatopsia. 

Jaeger  has  noticed  temporary  bluish  coloration  of  the  optic  nerve  after 
attacks  of  hysteria.  Anaesthesia  of  audition  is  usually  incomplete,  and  is 
accompanied  by  roaring  in  the  ears,  a  sensation  of  compression,  and  en- 
feebled hearing.  These  nervous  auditory  disorders  usually  occupy  only 
one  side,  and  disappear  spontaneously  or  after  appropriate  treatment. 

When  the  anrvsthesia  and  analgesia  are  generalized  {in  the  skin,  mus- 
cles, and  Joints),  a  very  curious  disorder  of  innervation  is  produced,  which 
was  described  for  the  first  time  by  Duchenne,  and  of  which  I  have  also 
observed  an  exam.ple  (Wien.  Med.  Presse,  5,  1867).  When  the  eyes  are 
closed,  or  during  the  niglit,  these  patients  are  incapable  of  performing  any 
motions,  although  they  imagine  that  they  have  executed  the  actions  which 
they  willed.  They  cannot  bring  their  muscles  into  play,  unless  they  look 
at  the  limb  which  they  desire  to  move. 

These  observations  led  Duchenne  to  accept  the  doctrine  of  the  existence  of  a 
special  muscular  sense,  which,  starting  from  the  muscles,  stimulates  the  brain,  and 
determines  the  choice  of  the  muscles  vvhiuh  are  to  be  brought  into  action. 

But  I  think  that  we  can  resort  to  simpler  and  more  natural  explanations  of  this 
phenomenon.  We  know,  in  fact,  that  each  sense  has  its  special  origin  in  the  central 
organ,  and  may  be  hindered  in  its  functions  by  various  causes,  either  because  its  ter- 
minal apparatus  has  lost  its  sensibility  to  external  influences,  in  consequence  of  a 
change  in  the  peripheral  nerves,  or  because  there  is  some  obstruction  in  the  central 
conductors. 

We  must  also  consider  another  important  circumstance.  While  the  hysterical  pa- 
tients in  question  are  unable,  when  the  eyes  are  closed,  to  voluntarily  excite  the  motor 
action  of  the  nerves,  in  order  to  accomplish  the  desired  movement,  the  influence  of  tJie 
will  upon  innervation  becomes  much  more  effective  when  aided  by  the  sense  of  sight.  When 
a  healthy  person  attempts  to  seize  an  object  (with  the  eyes  closed),  he  uses  an  entirely 
disproportionate  amount  of  force — sometimes  excessive,  sometimes  insufficient. 

This  regulating  action  of  sight  has  a  much  greater  influence  when  the  muscles,  ar- 
ticulations, and  cutaneous  nerves  are  completely  anesthetic. 

Hysterical  neuralgia. — Hysterical  neuralgias  sometimes  occur  along 
the  course  of  certain  nerves,  especially  after  excitement  or  hysterical  con- 
vulsions. They  undergo  rapid  modifications  with  regard  to  their  situation 
and  intensity,  and  are  accompanied  by  other  characteristic  signs  of  hys- 
teria. Cephalic  neuralgia  is  most  frequent,  occurring  in  the  frontal,  tem- 
poral, auricular,  or  occipital  regions.  Hemicrania  is  very  frequent,  es- 
pecially on  the  left  side;  the  clavus  hystericus  (Valentin«r)  usually  occu- 
pies a  circumscribed  part  of  the  sagittal  suture,  and  radiates  from  this 
point. 

We  may  also  meet  with  omalgia,  hrachialgia,  mastodynia,  intercostal 
neuralgia,  lumbar  neuralgia,  simple  or  double  sciatica,  and  a  pain  in  the 
coccygeal  region,  occurring  either  in  the  sitting  or  standing  position,  and 
described  by  Simpson,  Scanzoni,  and  Hoerschelmann  under  the  name  of 
coccygodynia  (hyperesthesia  of  the  branches  of  the  coccygeal  plexus). 


DISEASES    OP    THE    NERVOUS    SYSTEM.  33 

The  ruchialgia  is  a  spontaneous  dorsal  pain,  almost  always  increased 
on  pressure.  It  may  be  caused  either  by  a  neuralgia  of  the  lumbar  branch- 
es, or  by  irritation  of  the  posterior  branches  which  supply  the  skin  and 
muscles  of  the  dorsal  region,  or  of  the  sensitive  fibres  wiiich  Luschka  has 
discovered  in  great  number  in  the  vertebral  veins  and  vertebrfe.  Cardi- 
aUjia  and  enteralgia  are  observed  at  times.  Ovarahjia  is  mucli  more  fre- 
quent, and  has  been  especially  referred  to  of  late  by  Charcot  (fixed  iliac 
pain  of  Briquet).  It  occurs  with  or  without  appreciable  enlargement  of  the 
ovary,  compression  of  which  may  produce  an  hysterical  convulsion,  while 
energetic  pressure  will  moderate  and  sometimes  even  suspend  a  convulsion. 

The  motor  disorders  consist  either  of  irritation  of  the  motor  functions, 
as  in  spasms  and  contractures,  or  of  diminution  or  even  complete  aboli- 
tion of  these  functions,  as  in  paresis  and  paralysis. 

Hysterical  spasms. — Almost  all  hysterical  patients  present  an  abnor- 
mal motor  excitability,  which  appears,  in  the  slighter  forms,  as  vivacity 
and  precipitation  of  movements.  When  this  excitability  is  more  intense, 
it  gives  rise  to  contractions  of  certain  muscles  or  of  entire  groups  of 
muscles,  or  may  even  assume  the  form  of  convulsions. 

The  spasms  of  the  head  observed  in  hysterical  patients  are:  sjyas- 
modic  contractions  of  the  muscles  of  the  face  and  sjxism  of  certain  ocular 
muscles  (with  convergent  or  divergent  strabismus). 

In  the  cervical  region,  spasms  occur  in  the  sterno-inastoid  and  trape- 
zius muscles,  and  in  the  2:>haTynx,  larynx,  and  cesopJiagus.  When  the 
pharynx  is  affected,  spasms  develop  in  the  apparatus  of  deglutition,  and 
usually  occur  in  a  sudden  and  violent  manner  (contraction  of  the  trans- 
verse muscular  fibres  of  the  pharynx  and  the  upper  third  of  the  oesopha- 
gus, the  contraction  of  which  muscles,  according  to  Helmholtz,  very 
quickly  follows  their  stimulation).  The  spasms  in  the  muscles  of  deglu- 
tition may  even  compromise  alimentation,  as  I  have  observed  in  two 
cases,  in  which  galvanization  always  caused  immediate  cessation  of  the 
spasm.  Contraction  of  the  thoracic  portion  of  the  oesophagus  may  also 
occur  and  may  be  propagated  to  the  constrictors  of  the  pharynx,  and 
prevent  the  introduction  of  the  oesophageal  sound.  The  (jlohus  Jiyster- 
icus  (sensation  of  a  ball  rising)  is  merely  a  sensory  irritative  symptom. 
In  certain  forms  of  spasms  of  deglutition,  the  constriction  of  the  muscles 
of  the  lower  part  of  the  oesophagus,  and  perhaps,  also,  of  the  circular 
fibres  of  the  cardiac  extremity  of  the  stomach,  gives  rise  to  regurgitation 
and  vomiting  of  food. 

The  s^xtsmodic  contraction  of  the  laryngeal  muscles  appears,  in  the 
lighter  forms,  as  hysterical  laughter,  which  may  last  a  quarter  of  an  hour 
at  a  time,  and  is  sometimes  followed  or  interrupted  by  convtdsive  weeping. 
At  a  more  advanced  stage,  convulsive  cries  make  their  appearance,  under 
the  form  of  barking,  howling,  and  sneering.  At  other  times  the  sounds 
simulate  the  cries  of  different  animals,  and  may  exercise  a  contagious 
effect  upon  predisposed  subjects,  so  that  epidemics  of  hysterical  cries 
may  be  produced.  Spasm  of  the  glottis  occurs  in  rare  cases  from  the  re- 
flex effect  of  hyperoesthesia  of  the  laryngeal  mucous  membrane,  from 
irritation  of  the  recurrent  nerve.  Guisan  and  Dubois  mention  cases  in 
which  death  from  asphyxia  occurred,  and  Bell  and  Briquet  report  others 
in  which  the  danger  was  only  averted  by  resort  to  tracheotomy.  To  this 
category  also  belong  hysterical  asthma  (perhaps  from  spasm  of  the  bron- 
chial muscles)  and  hysterical  cough  (irritation  of  the  superior  laryngeal 
nerve).  Hysterical  yawning  results  from  spasmodic  movements  of  in- 
spiration, and  is  accompanied  by  other  spasmodic  phenomena. 
Vol.  IL— 3 


34 


CLiraCAL   TREATISE    ON 


The  spasmodic  phenomena  ichicJi  are  observed  on  the  part  of  the 
abdomen  consist  of  sobs,  eructations,  borborygmus,  and  spasms  of  the 
genito-urinary  apparatus.  The  sob  (or  hiccough)  is  a  clonic  spasm  of  the 
diaphragm,  with  noisy  penetration  of  the  inspired  air  through  the  glottis, 
retraction  of  the  epigastrium  and  hypochondrium,  followed  by  expiration. 
Hiccough  frequently  appears  as  the  precursor  of  an  hysterical  or  catalep- 
tic convulsion,  or  may  develop,  on  the  other  hand,  at  the  termination  of 
such  convulsions.  Hysterical  eructations  consist  in  the  expulsion  of  gas 
from  the  stomach,  with  very  marked  deglutition  of  air,  Borborygmus 
is  due  to  movement  of  the  intestinal  gases;  the  intestinal  contractions  are 
sometimes  appreciable  to  the  sight  and  touch. 

Spasm  of  the  vagina  (vaginismus)  is  a  painful  contraction  of  the  con- 
strictor cunni,  which  prevents  sexual  intercourse  and  even  hinders  the 
introduction  of  the  finger.  The  sphincters  of  the  bladder  and  anus  are 
also   sometimes   affected  with    spasmodic    contraction.      Goose-flesh  is  a 

very  frequent  phenomenon  in  hysterical  pa- 
tients, and  is  due  to  spasmodic  contraction  of 
the  muscular  fibres  contained  in  the  skin. 

Tonic  sjxisms  occur  in  the  neck,  limbs, 
and  abdomen  under  the  form  of  contractures, 
with  abnormal  positions  of  the  limbs.  These 
contractures  usually  appear  after  emotional 
excitement  or  hysterical  convulsions.  They 
generally  involve  the  knee,  wrist,  and  the  pha- 
langeal joints  of  one  hand  (Fig.  17);  in  rare 
cases,  spasmodic  club-foot  is  developed.  The 
contracture  is  situated,  by  preference,  in  the 
adductors  and  flexors  of  the  hand  and  fingers, 
and  is  characterized  by  the  fact  that  it  is 
not  only  associated,  in  the  majority  of  cases, 
with  paralysis  of  the  antagonists,  but  is  also 
accompanied  by  a  simultaneous  abolition  of 
the  functions  of  certain  other  muscles,  by 
anfEsthesia,  and  more  rarely  hy  hypenesthesia. 
Certain  forms  are  complicated  with  symptoms 
of  irritation  on  the  part  of  the  nerve-centres. 
I  had  under  observation  a  young  girl  who  suffered  from  hystero-epileptic 
convulsions  for  several  years.  These  were  folloAved  by  contracture  of 
the  right  tipper  limb  at  the  elbow  and  wrist,  with  continual  vibrations 
of  the  right  arm  /  the  same  phenomenon  was  apparent,  to  a  less  extent 
in  the  right  leg;  each  attempt  at  extension  increased  the  intensity  of 
the  tremor. 

Hysterical  convulsions  are  divided  into  partial  and  general,  and  those 
with  or  without  loss  of  consciousness.  The  muscles  of  the  limbs  are 
most  frequently  involved.  Strong  emotions  have  an  especially  injurious 
effect  upon  the  production  of  hysterical  convulsions. 

In  one-third  of  the  three  hundred  and  five  cases  collected  by  Briquet, 
the  hysteria  began  with  convulsive  seizures.  The  attacks  were  most  nu- 
merous in  the  first  year  of  the  disease,  and  in  ten  per  cent,  of  the  cases 
consciousness  was  unaffected  during  the  convulsions. 

The  hysterical  seizure  is  often  preceded  by  certain  prodromata,  such  as 
languor,  malaise,  slight  pains  in  the  legs,  tingling  in  the  limbs,  vesical 
tenesmus,  or  a  feeling  of  oppression  in  the  epigastrium.  In  the  majority 
of  cases  the  attack  develops  rapidly,  with  symptoms  of  reflex  irritation 


Fig.  17. — Hysterical  contracture  of 
left  upper  limb. 


DISEASES    OF    THE    NERVOUS    SYSTE>t. 


35 


of  the  medulla  oblongata,  palpitation  of  the  heart,  feeling  of  suffocation, 
spasms  of  the  pharynx,  and  hiccough.  The  reflex  acts  soon  extend 
to  various  patlis  in  the  cerebro-spinal  system  ;  consciousness  may  be 
preserved  in  great  part,  or  it  may  rapidly  disappear  in  the  vortex  of 
symptoms.  In  the  first  case  the  convulsive  movements  are  less  violent  and 
the  special  senses  are  less  involved,  but  the  patients  are  unable  to  speak, 
to  perform  any  voluntary  movement,  or  to  give  any  sign  of  intelligence. 
After  the  attack  they  remember  distinctly  the  pains  which  they  experienced 
in  the  head,  limbs,  and  epigastrium.  According  to  Briquet,  among  three 
hundred  patients  affected  with  hysterical  convulsions,  there  were  only 
thirty  in  whom  consciousness  remained  intact.  In  severe  hysterical 
paroxysms  the  patient,  after  palpitation  of  the  heart  and  loss  of  con- 
sciousness, gives  utterance  to  a  piercing  cry,  and  then  the  face  becomes 
pale  and  grimacing,  tonic  and  clonic  contractions  succeeding  one  another 
rapidly  in  the  muscles  of  the  face,  eyes,  and  jaw,  in  the  limbs  of  one  or 
both  sides,  in  the  muscles  of  the  back,  thorax,  and  abdomen;  then  follow 
spasms  of  the  glottis  with  symptoms  of  asphyxia,  tumidity,  and  cyanosis 


Fig.  18. 


of  the  face,  bloody  froth  at  the  mouth  (from  biting  of  the  tongue  or  lips), 
convulsive  respiration,  interrupted  by  cries,  automatic  movements  or 
retraction  of  the  head,  projection  of  the  pelvis  forward,  opisthotonos, 
pleurosthotonos,  or  other  analogous  symptoms.  These  cases  constitute 
the  affection  known  as  hystero-epilepsy.  (Fig.  18.)  At  the  close  of  the 
attack,  whidh  may  last  a  few  minutes  to  several  hours  under  the  most 
variable  aspects,  a  condition  of  exhaustion  often  develops,  with  a  sensation 
of  emptiness  in  the  head,  and  relaxation  of  the  limbs.    This  dramatic  scene 


36  CLINICAL    TREATISE    ON 

is  usually  followed  by  a  shower  of  tears,  by  an  abundant  development  of 
gas  in  the  stomach  and  intestines,  and  by  the  emission  of  a  large  quantity 
of  pale,  inodorous  urine.  In  rarer  eases  the  patients  sink  into  a  profound 
sleep  or  syncope,  or  into  a  condition  of  catalepsy,  delirium,  or  somnam- 
bulism. 

Hysterical  jyci^oly^^^- — Hysterical  patients,  as  a  rule,  suffer  from  a 
great  diminution  of  muscular  power.  Briquet  has  found  paresis,  or  paral- 
ysis, one  hundred  and  twenty  times  in  four  hundred  and  thirty  patients; 
Landouzy,  forty  times  in  three  hundred  and  seventy  cases.  The  limbs 
are  most  frequently  involved,  especially  on  the  left  side;  the  lower  limbs, 
the  muscles  of  the  trunk,  of  the  larynx  and  face  are  affected,  with  regard 
to  frequency,  in  the  order  mentioned;  paralysis  of  the  diaphragm  is  a  very 
rare  event. 

Facial  paralysis  in  hysteria  sometimes  coexists  with  paralyses  in  the 
limbs,  is  almost  always  upon  the  same  side  as  the  latter,  and  is  usually 
accompanied  by  anaesthesia  of  the  skin  and  special  senses.  Hysterical 
ptosis  and  alternating  paresis  of  the  motor  muscles  of  the  eye  have  also 
been  observed. 

Paralysis  of  the  pharyngeal  and  oesophageal  constrictors  have  been 
noticed  by  several  observers.  Paralyses  of  the  laryngeal  muscles  are 
more  frequent  and  better  understood.  Double  paralysis  of  the  vocal  cords 
may  develop  spontaneously;  it  often,  however,  follows  a  convulsion,  and 
is  accompanied  by  considerable  hyperaesthesia  of  the  isthmus  of  the  fauces 
(Tuerck).  According  to  this  author,  disorders  of  co-ordination,  rather  than 
paralysis,  constitute  the  cause  of  certain  cases  of  hysterical  aphonia. 

Paralysis  of  the  diaphragm,  first  described  by  Duchenne,  forms  one 
of  the  rarest  motor  disorders  in  hysteria;  Briquet  has  only  observed  it  in 
two  cases.  The  affection,  which  is  usually  obstinate,  is  characterized  by 
inversion  of  the  respiratory  rhythm  and  by  extinction  of  the  voice.  Dur- 
ing inspiration,  the  epigastrium  and  hypochondria  are  depressed  and  the 
thoracic  walls  are  elevated.  During  expiration,  the  abdominal  walls  are 
raised  and  the  thorax  contracts. 

Paralysis  of  the  extremities  may  be  limited  to  certain  portions  of  the 
limbs,  or  may  involve  an  entire  member;  in  very  rare  cases  it  affects  all 
the  limbs.  The  most  frequent  hysterical  paralyses  are  those  involving 
one  limb,  hemiplegia  and  paraplegia. 

Hemiplegia  (observed  by  Briquet  in  one-sixth  of  his  cases)  usually  ap- 
pears after  excitement  or  after  a  convulsive  seizure.  The  paralysis  is  gen- 
erally less  marked  in  the  upper  than  the  lower  limb,  which,  during  walk- 
ing, is  dragged  along  like  an  inert  mass.  Anresthesia  and  analgesia  of 
the  deeper  parts  frequently  coexist,  with  diminution  or  abolition  of  the 
functions  of  special  sense.  Paraplegia  (which  existed  in  about  one- 
twelfth  of  Briquet's  observations)  may  be  either  partial  or  complete;  it  is 
usually  accompanied  by  anaesthesia  of  the  lower  limbs.  Hysterical 
ataxia  also  develops  in  some  cases. 

Paralysis  of  the  bladder  almost  always  accompanies  hemiplegia  and 
especially  hysterical  paraplegia.  It  is  very  rebellious  in  such  cases,  and 
is  sometimes  complicated  with  anaesthesia  of  the  vesical  mucous  mem- 
brane. Paralysis  of  the  rectum  occurs  in  very  rare  cases,  and  is  accom- 
panied by  constipation,  tympanites,  or  even  anaesthesia  of  the  rectum. 

Electrical  reactions  in  hysterical p>aralyses. — Duchenne  first  called  at- 
tention to  the  following  characteristic  signs  of  hysterical  pftiralysis  :  in- 
tegrity of  electro-muscular  contractility,  with  marked  diminution  or  com- 
plete abolition  of  electro-muscular  and  electro-cutaneou^s  sensibility.      In 


DISEASES    OF   THE    NERVOUS    SYSTEM.  37 

some  exceptional  cases,  however,  the  electrical  contractility  of  the 
muscles  is  also  markedly  diminished.  We  have  previously  called 
attention  to  the  fact  that  in  certain  apoplectic  paralyses  or  those  due 
to  compression  of  the  cord,  in  which  the  paralysis  is  accompanied  by 
anaesthesia  of  the  deeper  parts,  the  electro-muscular  contractility  may  be 
preserved  and  the  electro-cutaneous  and  electro-muscular  sensibility  be 
abolished  as  in  hysterical  paralysis.  In  these  doubtful  cases  we  must 
have  recourse  to  other  signs  to  aid  us  in  the  differential  diagnosis. 

Faradization  of  the  nerve-trunks,  and  the  passage  of  strong  galvanic 
currents  from  the  vertebral  column  to  tho  plexuses,  nerves  and  muscles  of 
the  affected  limbs,  produce  energetic  contractions  in  hysterical  paralysis, 
although  the  patients  are  unconscious  of  them. 

Exploration  with  the  aid  of  electro-puncture  is  the  best  means  of 
ascertaining  the  depth  of  the  ana?sthesia.  In  severe  forms  even  the 
mucous  membranes  are  insensible  to  electrical  irritation. 

Disorders  of  vegetative  life. — On  the  part  of  respiration  we  frequently 
observe  an  abnormal  frequency  of  inspirations,  with  or  without  a  sensa- 
tion of  dyspnoea;  in  other  cases  there  is  a  real  want  of  air,  with  attacks 
of  asthma  and  asphyxia,  although  physical  examination  of  the  thoracic 
organs  reveals  nothing  abnormal.  Tlae  cardiac  functions  are  only  dis- 
turbed in  a  few  instances;  in  such  cases  we  notice  periodical  palpitation 
and  systolic  cardiac  bruits,  the  latter  being  due  to  antemia. 

The  digestive  organs  are  affected  in  various  ways.  Certain  patients 
take  very  little  nourishment,  experience  profound  disgust  for  certain 
dishes,  and  may  even  abstain  entirely  from  food  (usually  under  the  in- 
fluence of  a  pathological  mental  condition).  Other  patients  suffer  from 
bulimia,  and  can  hardly  satisfy  their  inordinate  appetite.  In  this  category 
we  may  also  mention  frequent  and  distressing  epigastric  pulsation,  belch- 
ing, obstinate  vomiting,  tympanites,  and  constipation.  Menstruation  is 
usually  very  irregular  and  scanty,  and  is  very  frequently  suppressed  for  a 
long  time.  Hiemoptysis  is  observed  in  some  cases  (vicarious  menstrua- 
tion). 

Retention  of  urine  (with  anaesthesia  of  the  vesical  mucous  membrane), 
to  which  hysterical  patients  are  very  subject,  requires  the  prolonged  use 
of  the  catheter.  Hysterical  ischuria  may  be  complete,  and  may  last 
twenty-four  or  thirty-six  hours  (Laycock),  in  consequence  of  excitement 
or  during  menstruation,  after  which  it  gradually  disappears.  Very 
curious  examples  have  been  observed  of  hysterical  oliguria  and  anu- 
ria, with  vomiting  of  matters  containing  urea. 

The  first  case,  published  by  Charcot  and  Grehaut,  occurred  in  a  patient  suffering 
from  hysterical  contracture,  hemianaesthesia,  and  hemiopia.  Retention  of  urine  soon 
occurred,  and  the  quantity  of  urine  withdrawn  by  the  catheter  grew  progressively 
smaller ;  the  patient  than  began  to  vomit.  She  was  carefully  watched  for  two  months, 
and  the  urine  obtained  during  this  time  did  not  average  more  than  eighty  grammes  a 
mouth.  After  being  anesthetized  with  chloroform,  the  quantity  of  urine  increased 
and  some  drops  wet  the  bed.  During  the  period  of  anuria,  the  patient  vomited  daily. 
The  vomited  matters  were  rich  in  urea ;  the  blood,  which  was  analyzed  once,  con- 
tained 0.036  grammes  of  urea  per  100. 

The  psychical  disorders  of  hysteria  are  manifested  in  the  slighter 
forms,  by  an  abnormal  sensitiveness  to  external  impressions,  by  the  sudden 
passage  from  gayety  to  sadness,  and  by  obstinacy  or  apathy;  there  is 
frequently  a  desire  of  attracting  attention.  The  more  severe  psychical 
changes  are  either  acute  or  chronic.  Acute  attacks  consist  of  hallucina- 
tions, delirium,  ecstasy,  or  even  of  mania  ;  they  generally  terminate  in 


38  CLINICAL   TREATISE    ON 

recovery,  and  the  patients  are  then  unable  to  recall  their  past  condition. 
Chronic  hysterical  j^sychoses  assume  the  form  of  melancholia  or  mania. 
The  mental  condition  develops,  according  to  Griesinger,  by  a  progressive 
increase  of  the  previous  intellectual  disorders;  the  invasion  is  sometimes, 
also,  acute,  as  after  emotional  excitement,  acute  diseases,  and  hysterical 
convulsions.  There  is,  at  first,  a  slight  change  in  the  character,  unusual 
vanity,  impatience  and  violence,  absence  of  volitional  power,  and  exces- 
sive uneasiness  of  the  patient  with  regard  to  her  health.  Then  follow 
disturbances  of  sleep,  digestion,  and  menstruation,  and  profound  melan- 
cholia, stupor,  and  an  irresistible  desire  to  remain  in  bed.  Erotic  mani- 
festations are  often  observed  in  this  condition  ;  it  rarely  terminates  in 
true  dementia.  Ecstasy  may  also  develop  in  this  state.  Somnambulism 
may  be  placed  in  this  category  of  phenomena  ;  the  patients  perform  a 
series  of  extraordinary  movements  during  sleep;  they  walk  around,  either 
with  a  fixed  look  or  with  the  eyes  closed,  returning  to  bed  after  a  longer 
or  shorter  interval.  If  they  are  suddenly  awakened,  they  utter  a  loud 
cry,  become  greatly  terrified,  and  are  often  seized  with  convulsions.  The 
next  day  they  remember  absolutely  nothing  of  the  events  of  the  preced- 
ino;  niarht. 

It  is  evident,  from  the  description  just  given,  that  in  somnambulism 
the  connection  of  the  mind  with  the  organs  of  special  sense  is  temporarily 
abolished,  but  that  the  faculty  of  forming  ideas  and  their  influence  upon 
the  production  of  movements  persist.  Thus,  while  a  centripetal  stimulus 
is  not  furnished  by  the  organs  of  special  sense,  the  impulse  derived  from 
the  cerebral  cortex  may  pursue  its  centrifugal  course  and  reach  the 
anterior  roots  through  the  foot  of  the  cerebral  peduncle.  The  language 
which  the  patients  utter  during  their  sleep,  and  the  airs  they  sing,  evi- 
dently prove  that  the  cells  of  the  cerebral  cortex,  as  the  basis  of  ideas, 
and  their  communications  with  one  another,  which  serve  for  the  associa- 
tion of  ideas,  functionate  actively,  and  that  movements  may  be  produced 
by  the  centrifugal  action  of  the  cells  of  the  cerebral  cortex  along  the 
corona  radiata. 

It  is  probable,  also,  that  a  certain  amount  of  consciousness  is  present 
in  such  cases,  but  of  a  character  so  fleeting  that  it  leaves  no  impression 
on  the  memory. 

The  psychical  phenomena  of  depression  in  hysteria  consist  of  an  in- 
clination to  sleep,  which  may  be  intensified  into  true  sopor  or  lethargy. 
Lasegue  described,  under  the  title  of  temjyorary  catalepsy  (Arch.  Gcnor. 
de  Med.,  18GG),  a  condition  in  which  the  patients,  when  the  eyes  were 
covered  with  the  hand,  became  cataleptic,  and  fell  into  a  more  or  less 
profound  sleep,  from  which  it  was  sometimes  difficult  to  rouse  them.  Som- 
nolence manifests  itself  with  varying  intensity  and  is  preceded  by  various 
spasmodic  phenomena.  In  the  slight  forms  it  consists  of  a  half-sleep 
into  which  the  patients  fall  from  time  to  time  in  order  to  satisfy  a  natural 
need;  in  the  severer  forms,  a  heavy  sleep,  like  that  of  drunkenness,  may 
be  prolonged  for  several  days. 

Somnolence  is  sometimes  transformed  into  complete  lethargy.  In  an 
observation  reported  by  Pfendler,  it  continued  uninterruptedly  for  six 
months.  There  were  eight  cases  of  lethargy  (lasting  one.  to  eight  days) 
among  four  hundred  and  eighty  cases  reported  by  Briquet. 

Respiration  becomes  infrequent  and  barely  perceptible,  the  pulse  is 
very  small  and  intermittent,  the  skin  cold  and  dry,  evacuations  from  the 
bowels  are  suspended  for  weeks,  and  the  bladder  must  be  emptied  with 
the  catheter.     We  must  resort  to  powerful  stimuli  in  order  to  awaken  the 


DISEASES    OF    THE    NERVOUS    SYSTEM.  39 

patients  for  any  length  of  time.  This  sleep  should  not  be  mistaken  for 
the  condition  of  somnolence  which  often  forms  the  termination  of  hyster- 
ical convulsions,  which  usually  lasts  but  a  short  time  and  is  followed  by  a 
certain  remission  in  the  symptoms  of  the  disease. 

Trance  in  Jiysteria. — It  now  remains  for  us  to  describe  the  trance  of 
hysterical  patients,  which  constitutes  the  severest  and,  fortunately,  the 
rarest  of  these  conditions  of  somnolence.  Several  cases  of  this  kind  are 
reported  by  Briquet  (loc.  cit.,  pp.  417-420). 

I  have  pointed  out  an  unmistakable  means  of  recognizing  the  persist- 
ence of  life,  based  upon  personal  investigations  and  observations  (Jahrb. 
d.  Ges.  d.  Wien.  Aerzte,  IV.  Heft,  l^TZ). 

I  have  demonstrated  by  experiments  upon  the  cadavers  of  patients,  of 
drowned  individuals  and  upon  amputated  limbs,  that  electrical  excita- 
hilitij  disappears  icitJdn  an  hour  a)id  a  half  to  three  hours  after  death. 
The  faradic  contractility  and  galvanic  reaction,  in  conformity  with  the 
law  of  their  responses,  diminish  from  the  centre  to  the  periphery,  the  ex- 
citability of  the  nerves  disappearing  sooner  than  that  of  the  muscles. 
The  diagnosis  of  death  may  be  made  with  certainty  after  the  abolition  of 
the  farado-galvanic  excitability,  even  \chen  the  joints  are  still  flexible  and 
the  temperature  of  the  rectum  is  raised  to  38°-37°  C,  and  that  of  the  ax- 
illa to  a2.5°-33°  C. 

The  value  of  these  observations  is  considerably  increased  by  their 
agreement  with  investigations  made  in  the  human  subject,  and  with  ex- 
periments upon  muscular  rigidity  in  living  animals.  I  have  made  experi- 
ments upon  animals  which  were  either  curarized  or  narcotized  with  mor- 
phine ;  one  of  the  iliac  arteries  and  the  crural  artery  (below  the  origin  of 
the  epigastric)  were  then  laid  bare  and  ligatured.  The  electro-muscular 
contractility  of  the  corresponding  limb  was  found  to  have  disappeared  at 
the  end  of  about  two  hours.  When  the  circulation  was  allowed  to  return 
freely,  the  electrical  contractility  was  gradually  restored.  After  artificial 
respiration  was  interrupted,  the  farado-galvanic  reaction  in  the  ligatured 
limb  disappeared  at  the  end  of  two  and  a  half  to  three  hours,  while  it 
persisted  much  longer  in  the  limb  which  had  not  been  deprived  of  blood. 

My  conclusions  have  also  been  verified  by  the  investigations  of  Crimo- 
tel  (De  I'epreuve  galvanique  ou  Bioscopie  electrique,  18G6). 

In  hysterical  trance,  as  in  profound  syncope,  the  cerebral  activity  may 
be  lowered  to  an  imperceptible  minimum;  or,  as  in  a  case  under  my  ob- 
servation, the  impressions  of  the  senses  (especially  of  hearing)  continue 
to  be  transmitted  in  part  to  the  cerebral  cortex,  by  the  centripetal  con- 
ductors of  the  corona  radiata,  while  the  centrifugal  stimuli  of  the  cortical 
cells  to  the  motor  ganglia  and  to  the  centre  of  language  are  temporarily 
suspended,  and,  consequently,  no  movement  can  be  performed,  no  word 
uttered.  An  analogous  condition  exists  in  nightmare,  when  the  most 
painful  impressions  attack  us  in  dreams,  and  we  are  unable  to  call  for 
help  or  to  perform  any  movement  in  order  to  escape  from  these  terrors. 

In  apparent  death  in  hysteria,  the  lowering  of  the  circulatory  and  re- 
spiratory functions  may  be  reduced  to  a  barely  perceptible  minimum, 
showing  the  slight  activity  which  the  nutritive  changes  undergo  in  these 
conditions. 

Vaso-7notor  disorders. — We  shall  first  speak  of  fever,  with  its  phe- 
nomena of  general  vascular  spasm  starting  from  the  medullary  centre 
(stage  of  chill),  and  the  subsequent  vascular  dilatation  (stage  of  warmth) 
with  warmth  and  perspiration;  the  latter  symptom  is  sometimes  observed 
irrespective  of  the  febrile  attack.     Hysterical  /eyer  usually  occurs  in  con- 


40  CLINICAL   TREATISE    ON 

sequence  of  emotional  excitement.  It  often  begins  with  a  chill,  followed 
bv  heat  and  congestion;  the  patients  experience  a  sensation  of  heat  in 
the  head  and  face;  they  sometimes  become  delirious  as  soon  as  they  close 
the  eyes;  they  have  convulsions  and  tremor,  the  tongue  is  dry,  the  appe- 
tite is  lost.  But,  as  I  have  observed  in  several  cases,  the  temperature  in 
the  axilla  does  not  rise  above  37.4°-37.6°  C,  despite  a  pulse  of  100  to  120, 
•while  the  temperature  of  the  skin  (measured  upon  the  face,  neck,  and 
thorax)  may  reach  35. 20-36. 4°C.  This  pseudo-febrile  condition  may  con- 
tinue several  days  (even  several  weeks,  according  to  Briquet),  and,  when  it 
disappears,  characteristic  paralyses  of  sensation  and  motion  remain. 
Briquet  collected  twenty  cases  of  this  kind. 

The  flashes  of  heat,  and  the  alternations  of  heat  and  cold,  so  often 
observed  in  hysteria,  are  almost  always  accompanied  by  redness  or  pallor 
of  the  skin,  and  form  part  of  the  disorders  of  vaso-motor  innervation. 

Salivatio7i  in  hysteria  is  avascular  secretory  neurosis,  due  to  irritation 
of  a  centre  in  the  medulla  oblongata,  according  to  the  recent  experiments 
of  Gruetzner  (Pfliiger's  Arch.,  VII.  Bd.,  1873).  According  to  this 
author,  salivation  follows  irritation  of  the  central  origin  of  the  chorda 
tympani  and  sympathetic  fibres.  It  is  a  rare  symptom  in  hysteria  (if  we 
exclude  those  cases  in  which  the  saliva  is  expectorated  on  account  of  the 
impossibility  of  deglutition).  In  one  of  these  cases,  according  to  Mitscher- 
lich's  analysis,  the  saliva  presented  an  acid  reaction,  a  light  specific 
gravity,  and  a  marked  diminution  of  its  characteristic  elements. 

We  observe  in  hysteria  (most  frequently  after  convulsions)  an  dbuix- 
dant  eynission  of  very  pale,  clear  urine,  deflcient  in  salts  ;  this  phenomenon 
is  caused  by  an  irritation  transmitted,  by  reflex  means,  from  the  sensory 
nerves  to  the  vaso-motor  centres  of  the  kidneys  in  the  medulla  oblongata 
(the  stimulus  then  passing  through  the  cord,  the  communicating  branch- 
es, the  plexuses  of  the  sympathetic  and  the  renal  plexuses).  Finally,  the 
joint  affections  described  by  Brodie  (hyperaisthesia  with  enlargement  and 
oedema)  must  also  be  referred  to  vaso-motor  hyperaemia  of  the  articula- 
tions. 

Pathological  Anatomy. 

The  opinion,  transmitted  to  us  from  the  ancients,  that  the  genital  or- 
gans must  be  considered  as  the  only  source  of  hysteria  in  the  female,  has 
caused  physicians,  even  until  very  recent  times,  to  devote  all  their  atten- 
tion to  the  examination  of  the  sexual  apparatus,  in  hysteria,  and  to  pro- 
fess themselves  satisfied  if  they  were  able  to  discover  in  the  cadaver  any 
change  whatever  in  the  uterus  or  its  annexes. 

While  Scanzoni  found  1,328  cases  of  hysteria  among  1,724  women  affected  with  dis- 
eases of  the  genital  organs,  this  proportion  falls  to  an  insignificant  figure  in  Briquet's 
tables.  According  to  a  recent  publication  by  Bemutz  (Gaz.  des  Hopit.,  Fev.,  1S74), 
among  32  cases  of  hysteria,  no  abnormality  was  found  in  the  genital  organs  in  19 
cases.  The  genital  organs  have  been  found  perfectly  healthy  in  a  large  number  of 
autopsies  upon  women  who  have  undeniably  been  hysterical.  Grisolle  (Gaz.  des  Hopit. , 
18,  1853)  and  Castiaux  (eod.  loc. ,  1873)  have  seen  congenital  absence  of  the  vagina  and 
uterus  in  two  undoubted  cases  of  hysteria. 

The  centred  nervous  system  has  been  scarcely  examined  in  autopsies  of 
hysterical  patients,  and  when  it  has  been  (as  in  Ollivier's,  Brodie's,  and 
Briquet's  cases)  the  observers  have  been  satisfied  with  naked-eye  exam- 
inations; the  negative  results  thus  obtained  have  led  them  to  believe  that 


DISEASES    OF   THE    NERVOUS    SYSTEM.  41 

there  was  no  material  change  in  the  nervous  centres.  Lancisi  observed 
an  interesting  fact,  which  has  hitherto  escaped  the  attention  of  other 
authors  (in  Morgagni,  Adversaria  Anat.,  I.,  p.  18):  "  Pluries  aniinadver- 
timur  in  hystericis,  quae  post  diros  convulsivos  motus  tonica  bracliii  vel 
cruris  convulsione  dui  venatae  tandem  diem  suum  obierunt,  ganylia  par- 
tibus  affectis  respoudbntla  ampltora  reddi,  liydatidibusque  obsessa^ 

A  lesion  may  be  found  upon  careful  examination,  as  is  shown  by  the 
following  case  reported  by  Charcot  (Gaz.  Hebdom.,  N°  7,  1865).  In  a 
woman,  who  had  suffered  since  the  age  of  fourteen  years  from  hysterical 
convulsions,  followed  by  motor  disturbances,  permanent  contracture  of  all 
the  limbs  and  of  the  muscles  of  the  trunk  developed  during  the  last  two 
years  of  life  ;  intelligence  remained  intact,  and  the  patient  died  from  an 
intercurrent  affection.  The  autopsy  res'ealed  the  presence  of  sclerosis  of 
the  lateral  columns,  extending  from  the  medulla  oblongata  to  the  lumbar 
enlargement,  with  partial  atrophy  of  the  anterior  roots. 


Etiology, 

If  we  examine  the  psychical  peculiarities  of  women,  in  whom  the  pas- 
sions and  feelings  play  such  a  variable  part,  we  will  find  that  the  germs 
of  hysteria  exist  in  the  majority  of  females,  but  that  the  soil  is  essentially 
different  in  different  individuals.  These  variations  depend  upon  the  indi- 
vidual predisposition.  The  predisposition  to  hysteria  is  very  frequently 
hereditary  (according  to  Briquet's  statistics,  hysterical  mothers  transmit 
the  disease  to  their  daughters  in  half  the  cases).  Other  nervous  diseases 
or  insanity  in  the  parents,  especially  in  the  mother,  may  lead  to  the  trans- 
mission of  analogous  conditions  to  the  children  and  of  hysteria  in  the 
daughters.  Education  plays  a  considerable  role  in  the  development  of 
the  disease.  The  prolonged  contact  of  children  with  older  persons  will 
develop  in  them  a  precocious  intelligence  and  a  want  of  simplicity;  the 
intellectual  faculties  of  young  girls  are  artificially  stimulated  at  the  ex- 
pense of  their  physical  powers;  their  sensibility  becomes  excessively  de- 
veloped, and  their  imagination  becomes  excited  by  theatrical  perform- 
ances, novels,  and  balls.  Feelings  are  thus  stimulated  in  women  which  are 
often  seriously  at  variance  with  the  stern  necessities  of  life.  All  these 
conditions  which  are  so  often  found  united,  especially  in  large  cities,  and 
which  are  frequently  accompanied  by  anfemia  and  chlorosis,  diminish  the 
energy  of  the  nervous  system  at  an  early  period  of  life,  stimulate  the 
brain  to  an  excessive  degree,  and  exaggerate  the  reflex  excitability  of  the 
spinal  cord. 

A  very  large  proportion  of  cases  of  hysteria  develop  at  the  age  of  pu- 
berty. The  first  symptoms,  in  more  than  half  the  cases  collected  in  Bri- 
quet's statistics,  were  manifested  between  the  age  of  twelve  and  twenty 
years;  one-third  of  the  cases  developed  from  the  fifteenth  to  the  twentieth 
years.  Menstruation  itself  does  not  favor  the  appearance  of  hysterical 
phenomena,  but  rather  the  disorders  of  menstruation  (suspension,  scanty 
or  abundant  flux,  combination  with  painful  symptoms).  Childhood  also 
furnishes,  according  to  Briquet,  a  large  contingent  to  the  number  of  cases 
of  hysteria.  Briquet  has  observed  its  occurrence  during  this  period  in  one- 
tenth  of  all  his  cases.  Although  this  statement  appears  to  me  to  be  ex- 
aggerated, since  we  are  rarely  justified  in  considering  as  h^'sterical  the 
convulsive  seizures  occurring  during  childhood,  I  can  nevertheless  state, 
from  personal  experience,  that  well-marked  attacks  of  hysteria  may  de- 


42  CLIIflCAL    TREATISE    OTT 

velop  in  children  of  both  sexes,  varying  from  ten  to  twelve  years  of  age. 
(I  shall  hereafter  report  a  very  clear  case  of  this  character,  occurring  in 
a  boy  ten  years  of  age.)  The  disease  rarely  occurs  after  the  age  of 
forty,  but  a  few  examples  have  been  observed  between  the  ages  of  fifty 
and  sixty  years. 

Hysteria  occurs  in  the  extremes  of  northern  and  southern  climates  (according  to 
the  statements  of  physicians  in  different  countries).  It  is  very  frequent  in  the  Orient, 
in  which  the  women  begin  to  menstruate  at  the  age  of  ten  years,  and  are  engaged  in 
no  serious  pursuits,  their  entire  aim  in  life  consisting  in  the  gratification  of  the  ca- 
prices of  their  master.  The  precocity  of  the  women,  especially  among  the  Polish 
Jewesses,  and  the  "manages  de  convenance"  which  are  so  numerous  among  them, 
are  powerful  causes  of  hysteria,  as  is  especially  well  recognized  by  Vienna  physicians. 
In  large  cities,  in  which  worldly  excitement  and  the  social  conditions  produce  such 
violent  impressions  upon  the  psychical  life  of  women,  hysteria  finds  a  fertile  field, 
especially  among  the  well-to-do  classes.  It  is  much  less  frequent  in  the  country  ; 
here  hard  labor,  privations,  and  ill-treatment  are  the  chief  factors  which  predispose 
certain  constitutions  to  the  development  of  hysteria.  Women  who  possess  an  im- 
pressionable and  susceptible  disposition  are  most  exposed  to  hysterical  affections, 
although  we  are  able  to  recognize  no  appreciable  influence  in  the  temperament, 
constitution,  or  various  conditions  of  nutrition.  The  character  of  the  occupation 
pursued  is  an  important  element ;  sedentary  pursuits,  prolonged  labor  within  doors, 
the  absence  of  sufficiently  varied  and  invigorating  muscular  exercise,  deprivation  of 
fresh  air  and  insufficient  nourishment,  are  the  unfavorable  factors  which  may  implant 
the  germs  of  hysteria,  t)y  interfering  with  hematopoiesis  and  with  the  energy  of  the 
nervous  system.  Religious  exaltation  and  excessive  devotion  also  favor  the  develop- 
ment of  hysterical  phenomena,  and  we  have  previously  alluded  to  the  fact  that  the 
''  convulsionnaires,"  the  "  possessed,"  and  the  epidemics  of  chorea,  which  occurred  in 
the  last  century,  consisted  in  a  great  measure  of  hysterical  paroxysms. 

The  female  sex  furnishes  by  far  the  larger  proportion  of  cases  of 
hysteria.  Those  who  maintained  the  Hippocratic  opinion,  that  the  sole 
source  of  hysteria  lies  in  the  uterus  and  its  annexes,  have  denied  the 
existence  of  the  disease  in  the  male  sex.  Even  physicians  of  the  present 
day,  such  as  Landouzy,  Monneret,  Louyer-Villermay,  share  this  incredu- 
lity. But  we  are  unable  to  accept  this  narrow  view,  contradicted  as  it  is 
by  certain  facts  which  it  is  unable  to  explain.  We  must  admit  that 
moral  causes,  which  very  often  lead  to  hysteria  in  the  female,  as  we  shall 
see  further  on,  may  also  produce  the  same  disease  in  delicately  constituted 
members  of  the  male  sex. 

Although  hysteria  does  not  belong  exclusively  to  the  female  sex, 
nevertheless  experience  teaches  us  that  the  proportion  of  cases  occurring 
in  men  is  very  small  when  compared  with  the  great  frequency  of  the 
disease  in  women.  Sydenham,  with  his  habitual  clearsightedness,  did  not 
fail  to  remark  that  one-half  of  the  chronic  affections  occurring  in  females 
are  due  to  hysteria.  Briquet,  after  numerous  observations,  states  that 
one-quarter  of  all  females  are  affected  with  hysteria,  and  that  one-half 
present  some  signs  of  hysteria,  or  an  excessive  iinpressionability  which 
differs  very  little  from  it.  Among  one  thousand  cases  of  hysteria,  either 
personal  or  taken  from  other  authors.  Briquet  cites  fifty  examples  which 
occurred  in  males.  The  predisposition  of  males  to  hysteria  is  therefore 
one-twentieth  of  that  of  females. 

The  symptomatology  of  hysteria  in  man  presents  the  same  character- 
istics as  ordinary  hysteria.  Briquet  reports,  in  addition  to  the  cases 
observed  by  other  authors,  seven  personal  observations  of  hysteria  in 
males,  in  which  the  following  characteristic  symptoms  were  noted:  hy- 
peraasthesia,  ana?sthesia,  and  analgesia,  under  the  forms  with  which  we 
have  previously  been  acquainted;  various  painful  phenomena,  spasmodic 


DISEASES    OF    THE    NERVOUS    SYSTEM.  43 

seizures,  convulsive  attacks,  with  partial  or  complete  loss  of  consciousness; 
ecstasy,  momentary  suspension  of  the  functions  of  special  sense,  variable 
deo-rees  of  paralysis  of  the  extremities,  with  diminution  or  loss  of  electro- 
cutaneous  and  electro-muscular  sensibility  and  preservation  of  electro- 
muscular  contractility.  Why  apply  the  term  hypochondria  to  such  cases 
which  are  so  evidently  hysterical  in  their  nature,  and  why  not  embrace 
identical  conditions  under  the  same  category  ? 

I  had  under  observation  a  boy,  eighteen  years  of  age,  pale  and  nervous,  whose 
mother  had  had  intermittent  hysterical  paroxysms,  and  who  suffered,  after  a  violent 
emotion,  from  cephalalgia,  vomiting,  tremor,  with  temporary  muscular  contractions 
and  pains  in  the  limbs,  and  from  a  rapidly  developing  feeling  of  fatigue  while  walking. 
Upon  examination,  I  found  ansesthcsia  and  analgesia  in  the  anterior  portion  of  the  lower 
limbs,  occupying,  anteriorly,  the  abdominal  region  as  far  as  the  border  of  the  ribs,  and, 
posteriorly,  the  gluteal  region  as  far  as  the  third  lumbar  -vertebraj.  The  trunk,  upper 
limbs,  and  face  were  perfectly  sensitive  above  this  limit  of  the  ansesthesia.  The  af- 
fection disappeared  in  about  two  weeks,  after  the  employment  of  cool  baths  and 
affusions  to  the  vertebral  column.     Guibout  has  lately  published  a  similar  case. 

Hysteria  is  also  observed  in  young  girls  during  the  first  ten  years  of 
life,  and  examples  have  been  reported  by  the  older  authors  (Willis,  Hoff- 
mann, Lepois,  etc.).  Briquet  has  observed  hysteria  in  eighty-seven  children, 
from  five  to  twelve  years  of  age,  under  the  form  of  convulsive  attacks,  of 
other  well-marked  spasmodic  seizures,  or  of  disorders  of  sensation  and 
motion.  In  almost  all  the  cases  there  was  a  history  of  hysterical  antece- 
dents in  the  mother,  of  hereditary  nervous  disease,  or  of  bad  treatment, 
fright  or  grief  ;  irritation  of  the  genital  apparatus  very  rarely  coexisted. 
In  one  family  (Obs.  33),  in  which  the  father,  two  brothers,  and  six  sisters 
suffered  from  well-marked  hysterical  paroxysms,  the  seventh  sister,  who 
was  nine  years  of  age,  had  her  first  attack  after  having  been  accidentally 
present  during  an  hysterical  seizure  in  one  of  her  sisters.  Her  attacks 
became  even  more  violent  after  marriage,  and  had  not  even  disappeared 
in  her  forty-sixth  year. 

Independently  of  the  hysteria  of  young  girls,  it  also  occurs  in  young 
boys,  though  this  is  a  very  rare  occurrence;  Briquet  has  not  observed  a 
single  case.  I  have  seen  two  cases  of  hysteria  in  boys.  The  first  oc- 
curred in  a  boy,  twelve  years  of  age,  a  spoiled  child,  whose  mother  suffered 
from  nervous  headache  and  gastralgia,  and  whose  sister  was  affected  with 
nervous  deafness.  Whenever  the  child  became  angry  he  was  seized  with 
spasms  throughout  the  entire  body  and  with  hiccough.  After  having 
left  his  home  and  lived  for  a  long  time  in  Switzerland,  he  was  completely 
cured  at  the  end  of  two  3-ears.  The  second  observation,  which  is  a  more 
remarkable  one,  occurred  in  a  boy  ten  years  of  age  ;  the  following  were 
the  most  striking  symptoms  : 

The  child  was  pale,  but  active  ;  the  mother  was  nervous.  Since  the  age  of  seven 
years  the  patient  had  suffered  from  spasm  of  the  extensors  in  the  lower  limbs,  which 
sometimes  disappeared  spontaneously,  and,  on  one  occasion,  after  an  agreeable  sur- 
prise. He  then  complained  of  dorsal  pains,  attacks  of  dyspnoea,  and,  at  the  age  0% 
ten  years,  after  having  been  severely  punished  by  his  tutor,  he  suffered  from  aphonia 
and  eructations. 

Laryngoscopic  examination  showed  paralysis  of  the  transverse  muscle,  and  abrupt 
movements  of  the  oesophagus,  which  was  drawn  upwards  and  dilated.  Faradization 
caused  the  reappearance  of  the  voice,  but  produced  intense  reflex  movements.  Ner- 
vine reraediep,  such  as  castoreum,  quinine,  and  moist  frictions,  were  useless.  Two 
weeks  later,  convulsive  laughter  and  general  convulsions,  with  loss  of  consciousness, 
supervened.  In  the  intervals  during  these  attacks  he  was  affected,  when  contra- 
dicted, with  true  ecstasy,  during  which  he  played  scales  and  waltzes  very  correctly  upon 


44  CLINICAL   TREATISE    ON 

the  piano.  If  the  father  began  to  sing  suddenly,  the  child  was  seized  with  convulsiona. 
His  responses,  at  such  times,  were  always  correct ;  but,  after  these  attacks,  he  re- 
membered nothing  which  had  transpired,  and  stated  that  he  had  been  asleep.  The 
skin  was  hyperEesthetic  over  a  large  surface ;  paraplegia  finally  developed,  which 
yielded  in  a  few  days  to  quinine  (0.5  daily) ;  the  voice  was  restored,  but  the  convul- 
sive attacks  only  disappeared  at  the  end  of  three  mouths. 

In  the  chapter  upon  catalepsy,  I  shall  mention  a  third  case  of  hysteria 
in  a  boy,  with  the  results  of  the  autopsy.  After  the  consideration  of  the 
causes  which  tend  indirectly  to  produce  hysteria,  we  will  discuss  those 
pathop^enic  conditions  which  lead  more  directly  to  the  development  of 
hysterical  affections.  The  principal  causes  included  in  this  category  are 
psychical  affections  and  irritations  arising  in  the  genital  apparatus. 

Among  the  psychical  Influences,  those  of  a  depressing  nature  have  the 
most  marked  effect  upon  the  development  of  h^^steria.  They  include  anx- 
iety, fear,  disappointed  love,  regret,  care,  and  jealousy.  The  effect  of  these 
causes  upon  the  naturally  impressionable  brain  of  certain  females,  and  the 
cessation  of  the  menses  which  often  goes  hand  in  hand  with  them,  espe- 
cially give  rise  to  the  convulsive  forms  of  hysteria.  Among  moral  causes 
we  may  also  mention  ill  treatment,  which  may  give  rise  to  hysteria  in 
women,  young  girls,  and  even  in  boys  (an  example  of  which  has  been 
reported  above). 

Another  fruitful  source,  and  one  which  was,  for  a  long  time,  consid- 
ered the  only  cause  of  hysteria,  consists  of  irritations  starting  from  the 
genital  apparatus.  These  irritations  may  be  local  or  general.  As  we 
have  stated  above,  local  diseases  of  the  genital  organs  (displacements 
tumors,  hypertrophy,  ulcerations  of  the  uterus,  affections  of  the  ovaries 
or  vagina,  leucorrhoea,  etc.),  may  give  rise  to  hysteria. 

The  cure  of  the  local  disorder  often  causes  disappearance  of  the  hj-s- 
terical  manifestations.  But  in  a  large  number  of  cases,  the  origin  of  the 
hysteria  can  be  traced  to  a  perversion  of  the  sexual  functions.  Thus,  onan- 
ism in  young  boys  and  girls,  excessive  continence  or  sexual  indulgence 
in  the  female,  the  prolonged  stimulation  of  sexual  desires  by  lewd 
plaj's  or  books,  are  very  frequently  the  cause  of  the  development  of 
hysteria.  In  this  regard  I  have  also  observed  another  pathogenic  con- 
dition, which  I  have  never  seen  referred  to,  viz.  '.pollutions  in  females. 

I  had  under  my  care  a  young  hysterical  female  who  performed  peculiar  suction 
movements  during  her  paroxysms,  during  sleep  and  in  a  condition  of  semi-conscious- 
ness. One  day,  as  her  consciousness  was  returning,  I  discovered  a  mucous  fluid  upon 
the  external  genitals,  although  the  genital  organs  were  normal.  After  having  often 
observed  a  similar  occurrence,  I  decided  to  warn  the  patient  that  she  was  concealing 
secrets  from  me  which  would  undoubtedly  result  to  her  detriment.  She  then  confess- 
ed that  she  secretly  read  light  novels  at  night,  that  she  then  had  erotic  dreams,  and, 
that  upon  waking,  she  felt  exhausted  and  worn  out.  The  hysterical  paroxysms  devel- 
oped after  this  condition  of  excitement  had  lasted  several  months.  A  trip  to  the  country 
and  bydrotherapeutic  measures  caused  the  disappearance  of  the  pollutions,  and  the 
hysterical  seizures  yielded  soon  afterwards.  In  another  case,  a  patient,  during  pro- 
found sleep,  saw  her  dead  mother  appear  before  her,  and  begged  her  pardon  for  con- 
cealing the  fact  that  she  had  a  mucous  discharge  from  the  genitals  after  voluptuous 
•reams,  blaming  the  obscene  books,  loaned  by  a  friend,  as  the  cause  of  the  discharge  and 
of  the  hysterical  paroxj'sms.  This  flux,  caused  hy  erotic  excitement  of  the  nervous 
system  is  produced  by  the  glands  of  Bartholin  and  by  the  acinous  glands  surrounding 
the  meatus  urinarius. 

Nature  of  Hysteria. 

'        With  the  exception  of.  Charcot's  case,  the  examination  of  the  nervous 
system  in  hysteria  (always  undertaken  without  the  aid  of  the  microscope) 


DISEASES    OP    THE    TSTERVOÜS    SYSTEM.  45 

has  merely  given  negative  results.  From  this  quarter,  therefore,  we  can 
receive  no  aid  in  forming  a  conception  of  the  nature  of  this  neurosis. 
Since  pathological  anatomy  sheds  no  light  upon  the  question,  we  are 
forced,  as  far  as  possible,  to  seek  its  solution  by  other  means,  without 
resting  upon  the  quicksands  of  theory.  We  will  endeavor  to  show  that 
the  data  at  our  command  are  sufficient  to  enable  us  to  form  a  correct  idea 
concerning  the  central  modifications  which  preside  over  hysteria. 

In  tracing  the  clinical  history  of  this  malady,  we  have  studied,  in  detail, 
hysterical  antesthesia  as  one  of  the  most  characteristic  sensory  disturbances. 
More  or  less  marked  paralysis  of  sensation  has  been  observed  by  Briquet 
in  sixty  per  cent,  of  his  cases,  and  by  Szokalsky  in  all  his  patients.  If 
we  also  take  into  consideration  the  cases  of  initial  hypertesthesia  which 
afterwards  pass  into  anaesthesia,  the  proportion  will  become  even  greater. 

If  Ave  differentiate  anaesthesia  and  analgesia,  we  will  find  (and,  in  this 
respect,  I  concur  entirely  in  Beau's  opinion)  that  many  hysterical  patients 
have  lost  their  sensibility  to  pain  (over  a  large  part  of  the  body),  but  that 
tactile  sensibility  is  often  preserved.  We  are  thus  brought  face  to  face 
with  a  condition,  which  Schiff  first  produced  experimentally,  and  which  v/o 
have  observed  in  traumatic  lesions  of  a  lateral  half  of  the  cord,  and  in  two 
cases  (reported  above  in  detail)  of  compression  myelitis  after  vertebral  ca- 
ries, a  condition  which  we  attributed  to  changes  in  the  nerve-cells  of  the 
gray  horns  demonstrated  by  the  microscope. 

Another  important  fact  which  is  brought  into  prominence  in  hysteria 
is  that  the  anaesthesia  and  analgesia  conform,  in  their  distribution,  to  the 
laws  established  by  Voigt  with  regard  to  the  distribution  of  the  cutaneous 
nerves,  and  we  have  observed  the  same  phenomenon  in  the  spinal  paralyses 
which  we  have  previously  discussed.  The  sensory  nerves  form,  at  the 
periphery,  a  sort  of  mosaic,  corresponding  to  an  analogous  arrangement 
in  the  spinal  cord,  although  the  design  is  much  more  complicated  here  on 
account  of  the  difference  in  the  amount  of  space.  According  to  the  de- 
gree of  change  in  this  central  distribution,  and  in  conformity  with  the  law 
of  excentric  sensations,  the  terminal  organ  will  give  rise,  on  its  part,  to 
corresponding  functional  disorders  of  varying  intensity  and  extent. 

The  hypothesis  of  an  alteration  in  the  peripheral  nerves  (admitted  by 
Valentiner)  is  contradicted  by  the  fact  that  a  lesion  of  the  nerve-rcots, 
explanatory  of  the  phenomena  of  local  anaesthesia,  has  never  been  demon- 
strated in  hysteria. 

This  hypothesis  is  still  further  combated  by  observations  of  general 
anaesthesia  of  sudden  origin,  as  after  friglit,  since  in  these  cases  Ave  can- 
not admit  that  the  transmission  of  nerve  force  has  been  suddenly  inter- 
rupted in  all  the  nerve-roots  and  nerves.  Finally,  the  theory  of  a  periph- 
eral affection  will  not  explain  those  multiple  forms  which  embrace  both 
motor  and  sensory  disturbances,  or  those  in  which  motion  or  sensation 
is  affected  separately  ;  or  why,  at  other  times,  the  sensibility  to  pain  or 
temperature,  or  the  muscular  sense  alone,  disappears. 

It  is  not  alone  by  way  of  exclusion  that  we  locate  the  lesion  of  hys- 
teria in  the  centres  (and  often,  indeed,  in  the  spinal  centre);  the  analyses 
of  the  cases,  which  we  have  reported  under  the  head  of  symptomatology, 
will  lead  us  to  the  same  conclusion.  In  fact,  if  we  regard  the  cord  as  the 
site  of  origin  of  hysterical  phenomena,  we  can  readily  explain  how  the 
morbid  increase  of  the  reflex  sensibility  of  the  gray  substance  produces 
the  general  increase  of  reflex  excitability  which  is  so  general  in  hysteria. 
We  can  thus  comprehend  how  temporary  obstructions  in  the  conducting 
functions  of  the  gray  substance  of  the  cord  will  be  followed   by  various 


46  CLINICAL    TREATISE    ON 

sensory  disturbances;  how  a  lesion  of  the  central  mosaic  will  be  accom- 
panied by  disorders  which  are  exactly  limited  to  the  projections  which 
these  central  parts  send  to  the  periphery;  how  the  amputation  performed 
by  Mayo,  in  a  case  of  intense  hyperttsthesia  of  the  knee,  was  unsuccessful, 
since  the  hyperesthesia  was  merely  the  peripheral  expression  of  a  condi- 
tion of  irritability  in  the  cord. 

It  is  evident,  from  the  2yrecedi7ig  remarks,  that  the  peripheral  disorders 
in  hysteria  merely  represent,  so  to  speak,  an  exact  reproductio7i  of  the 
central  changes,  and  that  the  latter  are  situated,  in  great  part,  in  the 
spinal  cord. 

This  rational  interpretation  of  the  symptoms  is  also  strengthened  by 
other  observations.  Electrical  exploration  teaches  us  that,  in  extended 
anaesthesia  of  the  limbs,  strong  galvanic  or  faradic  currents,  passing  from 
the  dorsal  spine  to  the  plexuses  or  nerve-trunks,  readily  produce  muscu- 
lar contractions,  but  no  sensation;  and  that,  when  improvement  begins, 
the  transmission  of  sensibility  is  restored  to  the  nerves /rom  tJie  cetitre  to 
the  2}Cfiph^^'y-  I  have  shown,  by  a  very  characteristic  example  {vide 
symptomatology),  the  important  part  which  the  vaso-motor  centres  as- 
sume in  anresthesia  and  hypera?sthesia,  in  which  we  can  observe  alterna- 
tions of  spasm  and  dilatation  of  the  vessels,  evidenced  by  local  modifica- 
tions of  circulation  and  temperature.  The  periodical  and  frequent  re- 
turns of  the  vascular  spasm  render  the  consequences  of  this  spasmodic 
ana?mia  more  persistent.  We  can  convince  ourselves  that  there  is  no  pro- 
found material  alteration  in  the  sensory  conductors,  if  we  remember  that 
even  anaesthesia  of  long  standing  sometimes  disappears  with  surprising 
rapidity.  We  must,  therefore,  attribute  a  large  p>art  of  the  symptoms  of 
hysteria  to  a  congenital  or  acquired  loant  of  resistance  on  the  part  of 
tlie  vaso-)notor  nervons  system. 

Motor  hysterical  disorders  are  also  due,  in  the  beginning,  to  a  simple 
functional  liypera?mia;  but,  in  certain  forms,  the  chronic  hyper^emia  may 
lead  to  an  inflammatory  process,  which  may  terminate  (as  in  Charcot's 
case)  in  secondary  changes  in  the  columns  of  the  cord  and  in  the  nerve- 
roots. 

l^he  brain  is  also  involved  in  hysteria.  This  is  chiefly  due  to  violent 
psychical  stimuli,  which,  originating  in  the  cerebral  hemispheres,  are 
transmitted,  according  to  Budge,  to  the  vaso-motor  conductors,  excite 
their  centre  by  reflex  action,  and  produce  alternations  of  flushing  and 
pallor,  and  unilateral  hypertesthesia  or  anfesthesia,-  and  stimulate  the 
cardiac,  abdominal,  and  secretory  nerves.  The  pallor,  weakness  of  the 
pulse,  and  loss  of  consciousness  which,  together  with  convulsive  symp- 
toms, are  observed  in  certain  cases  of  hysteria,  must  be  attributed  to 
reflex  spasm  of  the  cerebral  arteries  and  to  the  consequent  cerebral  anae- 
niia. 

It  is  evident  that  obstacles  are  also  present  in  the  perijyheral  con- 
ductors, since,  side  by  side  with  the  increase  of  the  electrical  excitability 
in  the  central  portion  of  the  nerves,  the  peripheral  ramifications  may  be 
found  insensible  to  the  current.  Another  phenomenon  appears  to  point 
towards  the  same  conclusion.  When  improvement  begins,  the  passage  of 
a  labile  galvanic  current  from  the  cord  to  the  plexus,  or  from  the  latter  to 
the  nerves,  produces  cutaneous  sensibility  and  conscious  movements; 
while  currents  acting  solely  upon  the  peripheral  nerves  or  muscles  pass 
unnoticed,  until  the  peripheral  ramifications  have  finally  recovered  their 
conductibility. 


DISEASES    OP   THE    NERVOUS    SYSTEM.  47 


Diagyiosis. 

Hysteria,  in  all  its  varied  aspects,  is  usually  recognized  without  any 
difficulty.  A  few  isolated  symptoms  of  the  disease  will  suffice  to  re- 
veal its  nature  to  the  practised  eye.  Certain  signs  are  almost  always 
present,  even  in  the  intervals  between  the  paroxysms,  which  disclose  the 
latent  forms  of  hysteria.  These  consist  of  an  abnormal  impressionability, 
dating  from  childhood,  and  the  frequent  occurrence  of  a  condition  of  men- 
tal excitement;  of  sensations  of  compression  or  tension  in  the  head, 
larynx,  or  epigastrium,  and  restlessness  of  the  limbs  after  vexation;  of 
vague  neuralgias,  of  pains  and  a  sensation  of  compression,  especially  re- 
ferred, according  to  Briquet,  to  the  epigastrium,  to  the  false  ribs,  particu- 
larly on  the  left  side  (pleuralgia),  and  to  the  vertebral  column;  often  of 
ovaralgia;  of  various  hyperjiesthesias,  analgesia  persisting  after  emotions 
or  hysterical  paroxysms,  and  its  combination  with  anaesthesia.  Inter- 
mittent spasms,  partial  paralyses,  and  contractures,  and  the  peculiar  re- 
sults of  electrical  exploration  in  these  cases,  furnish  more  positive  results. 

It  is  only  in  relatively  rare  instances  that  hysterical  paroxvsms  Avill 
be  confounded  with  other  spasmodic  affections  possessing  analogous 
symptoms.  In  almost  all  cases  we  will  be  able  to  obtain  sufficient  data 
to  form  a  positive  diagnosis,  if  we  take  into  consideration  the  pathogenic 
factors  and  the  enseiiihle  of  the  pathognomonic  symptoms.  Hystero- 
epilepsy,  beginning  with  loss  of  consciousness,  may  be  mistaken  for 
epilepsy  proper,  eclampsia,  tetanus,  or  trismus.  True  epilepsy  is  dis- 
tinguished by  the  frequency  of  nocturnal  attacks,  the  symmetrical  char- 
acter of  the  convulsions,  their  short  duration,  the  cry  which  is  almost 
always  heard  only  at  the  beginning  of  the  attack,  and  by  the  absence  of 
secondary  disorders  of  motion  and  sensation.  Hystero-epileptiform 
seizures  occur  with  the  greatest  frequency  during  the  day;  they  begin 
with  spasmodic  phenomena,  and  are  accompanied  by  repeated  cries;  the 
attacks  are  divided  into  several  periods,  terminate  by  hiccough,  weep- 
ing, and  a  characteristic  excretion  of  urine,  and  are  often  followed  by 
motor  and  sensory  disturbances.  In  hystero-epilepsy,  energetic  pres- 
sure over  the  ovary  may  modify  the  attack,  and  sometimes  even  termi- 
nate it,  a  phenomenon  which  is  never  observed  in  epilepsy  (Charcot). 
Furthermore,  a  succession  of  epileptic  fits  {status  epilep)ticus)  (jives  rise, 
according  to  Bourneville,  to  a  considerable  elevation  of  temperature  (as 
high  as  41°  C),  accompanied  either  by  delirium  or  apoplectiform  coma, 
and  constituting  a  grave,  if  not  absolutely  unfavorable,  prognostic  sign. 
This  elevation  of  temperature,  during  similar  conditions,  is  also  observed 
in  the  course  of  general  paralysis  of  the  insane,  of  disseminated  sclerosis, 
and  of  cerebral  hemorrhages  or  tumors.  Oti  the  other  hand,  even  v:hen 
the  hystero-epileptiform  attacks  folloio  one  another  tcith  u?nfsual  fre- 
quency, the  temperature  undergoes  no  appreciable  modification,  and  the 
general  condition  remains  satisfactory.  Wunderlich  (Arch,  der  Heilk.,  5. 
Bd.)  refers  to  a  patient  who  had  hysterical  attacks  of  this  character 
for  eight  weeks,  with  an  insignificant  rise  of  temperature,  and  who,  two 
days  before  death,  fell  into  a  condition  of  collapse,  with  a  temperature  of 
43  °  C.  The  autopsy  revealed  hyperremia  of  the  brain  and  medulla  oblon- 
gata and  pulmonary  oedema.  In  order  to  distinguish  puerperal  eclanip- 
sia  from  hysterical  paroxysms  of  pregnant  females,  we  must  pay  attention 
to  the  previous  history,  to  the  persistence  of  attacks  attended  with  complete 
loss   of  consciousness,  and   to  the  presence  of  albumen  and  casts  in  the 


48  CLINICAL   TKEATISE    ON 

urine.  It  is  believed  that  even  the  most  violent  hysterical  paroxysms 
do  not  compromise  the  life  of  the  foetus.  Trismus  and  tetanus  Sive  charac- 
terized by  the  fact  that  traumatism  plays  a  part  in  the  etiology,  by  the 
manner  of  the  extension  of  the  convulsions,  and  by  their  relaxation  and 
termination. 

Hypochondria  is  recognized  by  its  much  greater  frequency  in  man, 
its  rarity  before  the  thirtieth  year,  the  absence  of  convulsions,  the  con- 
stant preoccupation  of  the  patient  with  his  own  person,  the  frequency 
of  hallucinations  and  illusions,  and  its  almost  constant  termination  in 
insanity. 

A  condition  which  very  much  resembles  hysteria,  and  presents  con- 
siderable analogies  with  it,  is  the  abnormal  excitability  known  as  "  nervo- 
sisme,"  or  spinal  irritation.  The  factors  in  the  differential  diagnosis  have 
been  referred  to  in  the  chapter  on  Neuroses  of  the  Spinal  Cord.  Hysterical 
paralyses  are  sometimes  a  source  of  error  in  diagnosis.  Hysterical  liemi- 
plegia,  occurring  after  intense  excitement,  and  accompanied  by  loss  of 
consciousness,  may  be  mistaken  for  cerebral  hemiplegia.  We  have  dis- 
cussed the  question  of  differential  diagnosis  under  Cerebral  Apoplexy 
(Vol.  I.,  p.  53).  We  have  also  pointed  out  the  distinction  between  hyster- 
ical par  apleyia  and  spinal  paraplegia,  in  discussing  the  latter  affection. 


Prognosis. 

Despite  its  chronic  course,  hysteria  very  rarely  endangers  life.  Death 
may  occur  from  suffocation  during  an  attack  of  spasm  of  the  glottis, 
from  cerebral  hemorrhage,  from  syncope,  from  exhaustion,  or  from  an  inter- 
current disease  in  debilitated  patients.  The  most  unfavorable  prognosis, 
as  regards  recovery,  pertains  to  hereditary  hysteria,  or  to  constitutional 
hysteria  acquired  during  the  period  of  development  under  the  influence  of 
injurious  conditions.  Nevertheless,  puberty  or  marriage  may  give  a  favor- 
able turn  to  these  forms,  and  may  render  the  treatment  more  efficacious. 
Hysteria,  induced  by  anaemia,  chlorosis,  chronic  hemorrhages,  or  leucor- 
rhcea,  may  be  cured  by  improving  the  quality  of  the  blood  and  increasing 
the  vigor  of  the  nervous  system.  As  a  rule,  hysteria  is  more  grave,  ac- 
cording to  Briquet,  when  it  begins  during  3^outh  than  if  it  appears  be- 
tween the  twenty-fifth  and  thirtieth  years  of  life.  Those  forms  which 
attack  sanguine  subjects,  who  possess  a  certain  embonpoint,  and  those 
which  begin  with  convulsive  seizures,  as  is  especially  observed  in  the 
well-to-do  classes,  are  more  severe  and  rebellious  than  the  hysteria  which 
develops  slowly  in  weak  patients  and  under  the  influence  of  moral  causes. 
From  all  points  of  view,  hysteria  must  be  regarded  as  one  of  the  most 
distressing  diseases  of  females,  since  it  may  continue  to  the  menopause  or 
even  beyond;  and  we  should  not  bear  the  patients  any  ill-will  if  they 
complain  greatly,  and  if  they  manifest  less  resignation  than  their  phy- 
sicians, who  are  apt  to  adopt  the  theory  of  affectation  or  simulation. 

The  different  symptoms  of  hysteria  do  not,  by  any  means,  furnish  the 
same  prognosis.  As  a  rule,  the  disorders  of  sensation  are  less  obstinate 
than  those  of  motion. 

Cutaneous  hyperesthesia^  however  painful  it  may  be,  is  never  followed  by  serious 
consequences  ;  it  disappears  spontaneously  or  under  appropriate  treatment.  At  the 
beginning  of  the  affection  it  is  often  the  forerunner  of  anEEsthesia.  If,  on  the  other 
hand,  well-marked  and  widespread  ansesthesia  exists,  the  appearance  of  hyperaes- 
thesia  heralds  the  beginning  of  improvement  in  the  conducting  power  of  the  centrifu- 


DISEASES    OF   THE    NERVOUS    SYSTEM.  49 

gal  paths.  The  most  rebellions  and  annoying  form  of  hyperassthesia  is  that  occurring 
in  the  articulations.  An(esthesia  yields  so  much  the  more  readily,  the  less  comiJete 
and  widespread  it  is.  Slight  anassthesia,  following  emotional  excitement,  disappears 
Bpontaneously ;  but  that  which  results  from  prolonged  moral  causes  (grief,  anxiety! 
is  less  amenable  to  treatment.  A  more  severe  form  of  anaesthesia,  viz.,  that  which 
accompanies  hysterical  paralysis,  disappears  when  recovery  begins,  and  then  (as  we  have 
stated  above)  gives  place  to  hyperaästhesia,  which  is  almost  always  the  forerunner  of 
the  restoration  of  motor  power.  Anaesthesia  of  the  organs  of  special  sense  rarely 
continues  for  any  length  of  time.  Hysterical  7ieuralgias,  due  to  persistent  moral  causes, 
are  as  obstinate  as  they  are  painful.  They  present  great  changeableness,  and  are  often 
replaced  by  other  symptoms  of  sudden  origin. 

Among  the  motor  disturbances,  the  cotivulsive  phenomena  are  so 
much  the  more  grave  and  rebellious  to  treatment  the  more  frequently 
they  are  accompanied  and  followed  by  loss  of  consciousness.  Neverthe- 
less, the  prognosis  is  not  unfavorable  in  young  subjects  who  are  placed 
under  favorable  conditions.  The  contractures  which  develop  around  a 
hypertesthetic  articulation,  or  which  accompany  the  paralysis  of  a  limb, 
may  recover  even  after  they  have  lasted  a  year  or  more.  But  when  the 
contractures  appear  in  several  limbs,  and  even  in  the  trunk,  after  repeated 
paroxysms,  we  can  hardly  look  for  a  return  to  the  normal  condition. 
According  to  Tuerck,  the  paralysis  of  the  vocal  cords  may  disappear 
spontaneously;  it  is  sometimes  relieved  by  a  violent  emotion,  in  which 
the  patient  is  forced  to  cry  out,  or  during  a  convulsive  seizure.  With 
regard  to  paralyses  of  the  Ibyibs,  the  prognosis  is  more  favorable  in  partial 
paralyses.  Hemiplegias  are  much  more  grave  and  persistent;  paraplegias 
are  regarded  as  incurable.  I  have,  nevertheless,  seen  three  cases  of  re- 
covery in  young  subjects  who  were  otherwise  in  good  health,  and  the 
observations  of  Althaus  and  others  are  in  accord  with  my  own.  The  be- 
ginning and  progress  of  improvement  are  manifested  by  the  transition 
from  anfesthesia  to  hypernesthesia  of  the  skin  and  nerve-trunks  to  electri- 
cal irritation,  by  the  return  of  cutaneous  and  electro-muscular  sensibility 
from  the  centre  to  the  periphery,  by  the  return  of  the  power  of  perception 
of  passive  movements,  and  by  a  gradual  restoration  of  motion.  2'he 
psychical  disorders  of  hysteria  usually  follow  the  progress  of  the  general 
improvement.  Their  transformation  into  incurable  forms  of  insanity  is 
happily  a  rare  event. 

• 
Treatment. 

The  numerous  difficulties  which  the  treatment  of  hysteria  presents, 
and  the  frequent  annoyance  of  arriving  at  incomplete  results,  have  long 
since  induced  physicians  to  adopt  certain  precautions,  in  order  to  pre- 
vent the  appeaKance  and  development  of  hysteria  as  much  as  possible. 
Prophylaxis  affords  very  excellent  results,  when  the  causes  are  properly 
proportioned  to  the  effects  to  be  obtained.  The  necessity  of  this 
method  is  especially  marked  when  the  predisposition  to  hysteria  is  heredi- 
tary and  involves  a  certain  amount  of  danger.  Great  care  must  then  be 
bestowed  upon  the  education  of  the  child  in  its  earliest  years.  It  must 
be  provided  with  a  good  nurse,  and  should  be  habituated  to  cool  baths 
and  lotions  ;  it  should  be  allowed  to  play  in  well-ventilated  apartments. 
These  constitute  the  first  elements  upon  which  its  physical  education  must 
rest. 

As  soon  as  the  cJiild  can  walk  and  its  mind  begins  to  develop,  we 
should  endeavor,  by  rational  means,  to  increase  and  stimulate  its  physical 
and  moral  energies.  From  a  physical  point  of  view,  we  should  permit  the 
Vol.  IL— 4 


50  CLINICAL   TREATISE    ON 

child  to  run  freely  in  the  open  air,  should  avoid  burdening  her  with  a 
useless  amount  of  clothing,  should  send  her  out  of  doors  even  though  the 
weather  be  somewhat  unpleasant,  and  should  accustom  her  to  an  animal 
diet  and  to  regular  meals.  From  a  moral  point  of  view,  spare  the  child 
the  recital  of  frightful  tales  or  ghost  stories,  judiciously  strengthen  her 
natural  tendencies  and  her  desire  to  acquire  a  knowledge  of  surrounding  ob- 
jects. Accustom  the  children,  from  an  early  period,  to  a  knowledge  of  the 
harmlessness  of  little  animals  (spiders,  chafers,  toads,  etc.),  stimulate  their 
courao-e,  cause  them  to  associate  often  with  strangers,  and  accustom  them 
to  entering  dark  rooms,  etc. 

An  excellent  method  of  inuring  and  strengthening  children  (a  method  which  is  too 
little  known  and  even  less  applied)  consists  in  rubhiiyg  the  entire  body  (morning  and 
evening)  with  a  cloth  dipped,  at  first,  in  tepid,  and  then  gradually  in  cooler  and  cooler 
water.  This  practice,  continued  for  several  years,  summer  and  winter,  is  very  refresh- 
ing, and  stimulates  the  appetite  ;  after  the  rubbing,  the  child  should  be  compelled  to 
take  active  exercise.  Feeble  children  may  be  subjected  to  this  procedure  as  early  as 
the  fifth  year.  Swimming  and  gymnastics  produce  excellent  results  at  a  later  period. 
Children  must  not  be  permitted,  as  so  frequently  happens,  to  dine  or  associate  with 
adults,  since  these  generally  forget  that  children  are  present,  while  the  latter  pay  at- 
tention to  everything  that  transpires  around  them,  and  their  precocity  is  thus  stimu- 
lated. 

At  the  period  of  puberty,  when  womanhood  is  first  budding  into  full 
growth,  the  young  girl  must  be  the  object  of  careful  supervision  and 
continued  watchfulness.  We  must  continue  the  habits  of  childhood  as 
long  as  possible,  and  the  sexual  desires  must  not  be  stimulated  in  any 
manner.  Bodily  exercise;  attention  to  household  duties;  carefully  selected 
books,  which  do  not  excite  the  imagination,  but  point  out  the  vicissitudes 
of  life  ;  simple  habits;  intercourse  with  suitable  acquaintances;  abstinence 
from  extravagance  in  the  toilet;  precautions  against  coquetry  and  vanity; 
frequent  references  to  the  charms  of  simplicity  :  these  are  the  principal 
elements  of  the  moral  education,  and  should  be  the  objects  of  our  con- 
stant care  during  the  developmental  period.  We  are  thus  able  to  establish 
a  happy  equilibrium  between  the  various  faculties  of  the  mind.  Marriage 
should  not  be  one  of  "  convenance,"  but  in  accordance  with  the  affections 
of  the  young  woman;  it  is  well  known  that  a  happy  union  often  causes  the 
disappearance  of  hysterical  manifestations,  while  unhappy  marriages  fre- 
quently act  as'an  exciting  cause. 

The  first  object  of  medical  treatment  is  the  cure  of  the  hysteria,  and,  in 
those  cases  in  which  we  are  unable  to  obtain  a  mastery  over  it,  we  must 
endeavor  to  relieve  the  most  annoying  symptoms.  We  must,  above  all, 
pay  especial  attention  to  the  individual  modifications  existing  in  each 
case.  Every  hysterical  female  should  be  subjected  to  a  careful  vaginal 
examination  with  the  aid  of  the  speculum,  and  appropriate  treatment 
should  be  employed  for  the  relief  of  such  congestions,  displacements, 
alterations  of  texture,  and  ulcerations  of  the  uterus,  äs  may  be  present. 
Mild  ferruginous  preparations  are  serviceable  in  the  frequent  cases  of 
anfemia  and  chlorosis.  Ferruginous  mineral  waters,  slightly  charged  with 
carbonic  acid,  are  well  tolerated  in  small  doses  (from  half  a  glass  to  a 
glass),  especially  when  they  are  followed  by  moderate  exercise  in  the  open 
air.  If  gastric  disorders  (cardialgia,  vomiting,  anorexia)  coexist,  the  use 
of  iron  may  be  preceded,  for  some  time,  by  the  administration  of  small 
doses  of  quinine,  and  of  the  bitter  tonics.  When  the  quality  of  the 
blood  is  defective,  all  attempts  to  restore  the  menstrual  discharge  are  un- 
availing and  needlessly   irritating.      Plethoric   hysterical  patients   react 


DISEASES    OF   THE    NERVOUS    SYSTEM.  51 

less  energetically  to  emmenagogues,  although  these  sometimes  fail,  even 
here,  to  effect  their  object.  Bleeding,  which  was  formerly  practised  in 
these  cases,  is  discarded  at  the  present  time.  Briquet  applied  wet  cups 
along  the  spinal  column  in  robust  patients  suffering  from  convulsive 
seizures.  I  have  derived  benefit  in  similar  cases,  and  in  rachialgia,  from 
the  prolonged  application  to  the  back  of  an  india-rubber  bag  filled  with 
cold  water.  Good  effects  are  also  obtained  in  these  patients  from  the 
whey-cure,  and  from  the  methodical  employment  of  the  grape-cure. 

The  so-called  anti-hysterical  remedies  have  lost  much  of  their  former 
reputation.  They  relieve  the  spasmodic  seizures  and  act  as  sedatives, 
but  they  possess  no  specific  curative  action.  Castoreum  enjoys  great 
favor  among  physicians;  it  may  be  prescribed  as  it  is  found  in  nature,  or 
under  the  form  of  powders  or  pills.  On  account  of  its  high  price,  we 
may  also  employ  the  tincture  of  castoreum,  or  the  ethereal  tincture  of 
castoreum  added  to  aqua  laurocerasi,  or  other  similar  preparations  (tinc- 
ture of  asafoetida  or  valerian),  giving  ten  to  fifteen  drops  upon  a  lump  of 
sugar.  Valerian  is  especially  employed,  in  spasmodic  attacks,  under  the 
form  of  tincture  or  extract,  and  most  frequently  as  the  infusion,  either 
internally  or  in  enemata.  It  is  often  given  in  combination  with  a  metal, 
as  valerianate  of  zinc,  in  increasing  doses.  Asafoetida  is  used  in  the 
foi'm  of  tincture  or  ethereal  solution,  associated  with  other  remedies  to 
which  we  shall  refer  at  a  later  period.  In  hysterical  spasms  and  meteor- 
ism,  it  is  given  in  an  enema,  in  the  form  of  a  powder  mixed  with  the 
yolk  of  an  egg;  it  may  be  given  to  fastidious  patients  in  pill  form.  [I},. 
Asafoetida,  pulv.  valerianee  rad.,  ää  5  grains;  extr.  anthemidis  q.  s.,  ut.  f. 
pil.  No.  50.    Sig.  Pil.  2-4  t.  i.  d.) 

Ergot  (under  the  form  of  the  infusion,  in  enemata  and  vaginal  injec- 
tions), galbanum,  lupulin,  and  camphor  are  rarely  employed  alone,  but 
are  associated  with  other  substances,  to  relieve  the  irritative  phenomena 
of  hysteria.  The  same  remark  holds  good  with  regard  to  the  aromatic 
spirits  of  ammonia,  aromatic  infusions,  and  ethereal  oils  (the  ethereal  oil 
of  chamomile  (1-2  drops  upon  3-4  grains  of  sugar,  and  divided  into  six 
parts)  is  recommended  on  account  of  its  pleasant  odor  and  taste). 

Among  the  metallic  antispasmodics,  we  may  mention  arsenic,  which 
Romberg  prescribed,  under  the  form  of  Fowler's  solution  (3-4  drops  t.  i.d.),, 
in  hysterical  neuralgias  and  convulsive  affections;  it  is  also  administered 
as  the  Asiatic  pills,  or  as  the  arseniate  of  iron  (4-5  milligrammes),  when 
the  patient  is,  at  the  same  time,  ansemic.  We  may  also  employ  the  vari- 
ous compounds  of  zinc,  nitrate  of  silver,  and  subnitrate  of  bismuth  (em- 
ployed by  Gendrin,  especially  in  gastralgia).  The  action  of  these  metallic 
preparations  is  merely  palliative  and  temporary. 

Narcotics  are  well  tolerated  by  the  majority  of  hysterical  patients, 
provided  we  begin  with  small  and  gradually  increasing  doses.  Subcuta- 
neous injections  of  morphine  relieve  the  spasms,  the  hiccough,  the  hy- 
peraesthesia,  and  the  insomnia.  Opium  (either  crude  or  in  tincture,  in 
enemata)  is  highly  praised  by  Gendrin  and  Briquet.  Gendrin  begins 
with  0.50,  and  increases  the  dose  to  0.60-0.75  per  diem;  the  hysterical  seiz- 
ures improve  as  soon  as  symptoms  of  narcotism  appear,  and  the  dose  should 
then  be  diminished  until  somnolence  has  disappeared.  Recovery  is  said 
to  occur  under  this  plan  of  treatment  in  more  than  half  the  cases.  I  have 
rarely  obtained  a  positive  cure  from  the  use  of  this  drug,  but  rather  a  con- 
siderable improvement  in  the  irritative  phenomena.  Belladonna,  either 
alone  or  combined  with  quinine,  is  useful  in  convulsions  and  in  disorders 
of  deglutition  J  atropine  renders  good  services  in  convulsive  seizures  and 


52  CLINICAL    TEEATISE    ON" 

in  obstinate  hiccough.  It  must  be  given  cautiously,  especially  when  ad- 
ministered hypodermically.  Inhalation  of  chloroform  (stopping  short  of 
complete  anaesthesia)  is  employed  in  severe  and  painful  paroxysms;  a  few 
inhalations,  given  at  intervals,  will  diminish  the  number  and  violence  of 
the  attacks.  When  the  inhalations  are  too  frequent  and  are  carried  too 
far,  they  are  sometimes  followed  by  extreme  exhaustion. 

Finally,  we  may  mention  two  new  substances  which  have  been  tried 
in  hysteria,  viz.,  curare  and  bromide  of  potassium.  In  two  cases  of  epi- 
leptiform hysteria  I  obtained  no  benefit  from  the  prolonged  employment 
of  subcutaneous  in jections  of  curare  (0.05  of  curare  to  5-10  grains  of  water, 
with  the  addition  of  3-4  drops  of  absolute  alcohol;  5-10  milligrammes  in- 
jected at  one  dose).  In  many  cases  I  have  seen  large  doses  of  bromide  of 
potassium  (3-5  grammes  daily,  in  wafers)  diminish  the  reflex  excitability 
and  erotic  propensities,  and  relieve  the  insomnia;  on  the  other  hand,  its 
effects  were  but  slight  in  other  patients. 

Baths  play  an  important  part  in  the  treatment  of  hysteria.  The  older 
physicians  used  them  very  largely,  and  Pomme  (vide  Traite  des  Affections 
vaporeuses,  Lyon,  1767)  allowed  his  patients  to  remain  from  six  to  ten 
hours  in  a  tepid  bath.  Thermal  waters  are  employed  in  spasmodic  and 
neuralgic  forms  and  in  hysterical  contractures.  Among  the  watering- 
places  indicated  in  such  cases,  we  may  mention  Pfaeffers,  Schlangenbad, 
Wildbad,  Baden-Baden,  Gastein,  Teplitz,  Tueffer,  and  Neuhaus,  whose 
good  effects  are  due  not  alone  to  the  temperature  of  the  waters,  but  also,  in 
great  part,  to  the  change  produced  in  the  habits  of  life  of  the  patient.  In 
hysteria  of  anaemic  origin,  benefit  is  derived  from  the  waters  of  Spa,  Pyr- 
mont, Franzensbad,  Szilacs,  Rohitsch,  or  from  the  indifferent  cold  waters 
of  Voeslau  and  Tobelbad;  in  abdominal  cramps,  neuralgias,  articular  pains 
and  contractures,  slime-baths  are  indicated,  and,  in  delicate  patients,  they 
should  precede  the  use  of  ferruginous  baths,  or  of  small  quantities  of  fer- 
ruginous mineral  Avaters  taken  internally.  In  certain  abdominal  disorders 
(yellowish  complexion,  tenderness  over  the  liver,  digestive  disorders)  we 
may  prescribe  the  waters  of  Kissingen,  Marienbad,  Carlsbad,  Vichy,  etc. 

Sea-bathing  possesses  indisputable  advantages  in  the  treatment  of  hys- 
teria; the  calm  waters  of  the  Baltic  are  preferable  for  delicate,  nervous 
constitutions,  and  the  North  Sea,  with  its  stronger  billows,  may  be  recom- 
mended in  torpid  constitutions.  On  account  of  the  excessive  sensibility 
of  the  majority  of  hysterical  patients,  hydrotherapeutics  should  be  em- 
ployed, at  the  onset,  in  its  mildest  forms.  The  action  of  cold  is  as  injuri- 
ous as  the  exciting  effect  of  warm  baths. 

We  may  commence  by  washing  the  entire  body  in  a  half-bath,  at  a 
temperature  of  24°-22°  C,  and  gradually  adding  colder  water.  At  a  later 
period  we  may  employ  frictions  with  a  cloth  dipped  in  water  at  18°-16°  C, 
and  followed  by  a  half-bath  at  24°-18°  C,  with  affusions  to  the  vertebral  col- 
umn. In  spasmodic  and  neuralgic  attacks,  the  wet  pack  (continued  until 
the  return  of  warmth  to  the  body)  and  the  half-bath  are  useful;  in  ab- 
dominal pains  and  sexual  erethism,  we  prefer  sitz-baths,  followed  by  moist 
frictions;  in  addition,  we  may  advise  the  patient  to  wear  a  moist  waist- 
band, renewed  several  times  a  day,  or  the  caoutchouc  bag  to  which  we 
have  previously  referred,  and  may  also  prescribe  small,  but  frequently  re- 
peated, enemata  of  cold  water.  Hydrotherapeutic  treatment,  continued 
perseveringly  for  a  long  time,  diminishes  the  extreme  impressionability  of 
hysterical  patients,  strengthens  them,  and  increases  their  power  of  resist- 
ance to  irritating  influences,  stimulates  the  organic  functions,  combats  the 
anajmia,  calms  the  abnormal  excitability  of  the  peripheral  nervous  system, 


DISEASES    OF   THE    NERVOUS    SYSTEM.  53 

and,  by  diminishing  the  morbid  increase  of  reflex  power,  relieves  the  vio- 
lence of  the  spasmodic  symptoms.  Even  chronic  forms,  which  are  com- 
bined with  severe  paroxysms  of  convulsions,  are  susceptible  of  recovery 
under  this  plan  of  treatment. 

With  regard  to  the  electrical  treatment  of  various  hysterical  phenom- 
ena, we  may  derive  benefit  from  faradization  in  hyperaesthesia  by  em- 
ploying strong  secondary  and  progressively  increasing  currents  (Fromm- 
hold),  one  of  the  previously  moistened  conductors  being  applied  to  the 
vertebral  column,  and  the  other  electrode  (which  is  made  very  broad) 
being  passed  up  and  down  over  the  affected  portions.  If  the  hyperfesthesia 
is  very  intense,  a  galvanic  current  should  be  passed  several  times  through 
the  nerve  plexuses  or  trunks  during  chloroform  ansesthesia  (Benedikt),  or 
after  a  subcutaneous  injection  of  morphine,  as  I  have  done  with  good  re- 
sults. In  neuralgias  we  may  pass  the  uninterrupted  constant  current 
through  the  vertebral  column,  and  from  thence  to  the  affected  nerves. 

Anaesthesia  may  be  combated  in  the  same  manner  as  the  hyperaesthe- 
sia, by  passing  the  electrical  brush  over  the  anaesthetic  parts,  or  by  ap- 
plying the  negative  pole  of  a  strong  galvanic  battery  until  the  appearance 
of  sensibility  combined  with  redness  of  the  skin.  If  the  anaesthesia  ex- 
tends to  the  deeper  parts,  it  is  best  to  moisten  the  skin  before  applying 
the  electrical  brush;  when  the  sensibility  increases,  we  may  diminish  the 
force  of  the  current.  In  the  treatment  of  paralysis,  we  must  resort  to 
faradization  of  the  muscles,  or  alternate  this  measure  with  galvanization 
of  the  nerve-trunks,  starting  from  the  nerve-roots  and  plexuses. 

Contractures  are  treated,  like  paralyses,  with  mixed  currents.  Apho- 
nia may  be  cured  by  faradization  through  the  skin,  or  by  intra-laryngeal 
faradization,  by  means  of  a  conductor  in  the  form  of  a  catheter.  In 
spasms  of  deglutition,  benefit  is  derived  from  galvanization  of  the  hypo- 
glossal nerves;  in  hiccough,  from  galvanization  or  faradization  of  the 
phrenic  nerves;  in  meteorism,  from  faradization  of  the  epigastric  and  ab- 
dominal regions. 

In  conclusion,  we  will  make  a  few  remarks  upon  the  moral  treatment 
of  hysteria.  In  certain  cases  we  may  obtain  good  effects  by  appealing 
to  the  volition  of  the  patients;  but  at  other  times,  in  weak  and  long-suf- 
fering individuals,  it  will  be  as  useless  to  expect  from  them  the  exercise 
of  self-control  and  of  muscular  power,  before  the  general  condition  has 
improved,  as  it  is  to  look  for  the  production  of  harmony  in  a  poorly-con- 
structed instrument. 


CLASS      V.  ■ 


SPASMODIC  CEREBRAL  AND  SPINAL  NEUROSES. 


CHAPTER   XXVIII. 

CATALEPSY. 


We  shall  now  pass  to  the  study  of  the  spasmodic  affections  which  are 
due  to  irritation  of  the  brain  or  cord,  and  shall  first  take  up  the  consider- 
ation of  catalepsy,  one  of  the  most  interesting  of  these  neuroses. 

Catalepsy  is  an  intermittent  neurosis,  characterized  by  a  complete  or 
partial  abolition  of  consciousness  and  sensibility,  with  abolition  of  volun- 
tary motion,  and  persistence  of  the  position  in  Avhich  the  limbs  are  found 
at  the  commencement  of  the  attack,  or  of  the  attitudes  in  which  they  are 
artificially  placed,  until  they  finally  yield  to  the  action  of  the  force  of 
gravity.  Catalepsy  is  not,  properly  speaking,  an  independent  disease, 
but  merely  one  sj^mptom  of  various  affections  of  the  nervous  system. 
But  the  peculiar  character  of  its  manifestations  has  induced  the  majority 
of  authors  to  treat  of  it  as  a  distinct  morbid  entity. 

Our  knowledge  of  the  anatomical  lesions  in  catalepsy  is  extremely  im- 
perfect, since  a  fatal  termination  is  exceedingly  rare.  In  two  cases  in- 
flammatory exudations  or  alterations  were  found  in  certain  central  organs. 
We  shall  refer  to  them  in  detail  in  the  discussion  upon  the  nature  of  cata- 
lepsy. 

The  first  case  was  published  by  Schwartz  (Rigaer  Beitr.  Bur  Heilk.,  1857,  Bd.  IV., 
p.  118),  and  occurred  in  a  boy,  seven  years  of  age,  who  was  seized  with  persistent 
gastric  pains  after  the  receipt  of  an  injury.  These  were  superseded,  upon  the  eigh- 
teenih  day  of  the  disease,  by  choreiform  phenomena,  attended  with  disorders  of  sight 
and  abolition  of  speech.  These  symptoms  ceased  at  the  end  of  six  weeks,  and  were 
followed  by  gastralgia,  constriction  of  the  pharynx,  and  asthmatic  symptoms;  this 
condition  had  terminated  at  the  end  of  the  seventh  week,  and  a  cataleptic  and  tetanic 
condition  (with  wax-like  mobility)  was  then  observed.  Despite  the  use  of  narcotics, 
induced  electrical  currents,  and  baths,  the  alternations  of  spasm  and  relaxation  con- 
tinued for  more  than  two  years,  and  the  patient  finally  died  of  anasmia  and  cachexia. 
The  autopsy  revealed  an  abundant  collection  of  serum  in  the  cavity  of  the  arachnoid, 
softening  of  the  optic  thalami  and  corpora  striata,  especially  on  the  left  side,  and  of 
the  optic  nerves  as  far  as  the  chiasm ;  upon  the  posterior  surface  of  the  cord  was 
found  a  reddish  brown,  gelatinous  substance,  covering  the  dvra  mater,  adherent  in  pincts, 
and  extending  fr&m  the  cervical  to  the  lumbar  region.  The  cord  appeared  normal; 
unfortunately,  no  microscopical  examination  was  made. 

The  second  case,  published  by  Meissner  (Arch.  d.  Heilk.,  1860,  p.  512),  occurred  in 
a  shoemaker,  a3t.  forty-seven  years,  who,  without  known  cause,  had  been  affected, 
for  six  years,  with  catalepsy.  During  the  last  three  years  he  suffered  from  epilepti- 
form spasms  upon  the  right  half  of  the  body,  with  paralysis  of  these  parts  in  the 
intervals  of  the  attacks  ;  the  patient  died  with  symptoms  of  mania  and  epilepsy.     At 


56  CLINICAL   TREATISE    ON 

the  autopsy  an  epithelioma  was  found  in  the  anterior  cerebral  fossa,  above  the  ethmoid, 
and  starting  from  the  dura  mater;  the  anterior  third  of  the  right  hemisphere,  extending 
to  the  cortex,  was  markedly  softened,  together  icith  the  external  portion  of  the  nght  corpus 
striatum. 

Symptomatology. 

Catalepsy  rarely  begins  suddenly,  and  usually  occurs  in  the  form  of 
paroxysms,  after  prodroniata,  consisting  of  nervous  excitement,  insomnia, 
headache,  intellectual  malaise,  illusions  of  the  senses,  hiccough,  or  slight 
convulsions.  When  the  attack  occurs,  the  muscular  system,  usually  in 
its  entirety,  rarely  involving  merely  certain  limbs,  is  affected  with  a  sud- 
den stiffness.  The  patients  remain,  as  if  petrified  by  the  head  of  Medusa, 
in  the  position  which  they  had  last  assumed,  the  features  immovable,  the 
eyes  having  a  wild  expression  and  directed  forwards  and  upwards,  the  eye- 
lids sometimes  closed.  In  the  beginning,  the  muscles  are  tense,  and  resist 
passive  motion;  after  a  certain  period  this  tension  and  resistance  dis- 
appear, and  give  place  to  the  peculiar  condition  known  asßexibilitas  cerea 
(ioaxen  flexibility).  A  slight  impulse  to  the  upper  limbs,  the  hands,  or 
fingers  then  suffices  to  fix  the  large  or  small  joint  in  the  most  abnormal 
attitudes  for  several  minutes;  on  account  of  the  weight  of  the  lower 
limbs,  a  greater  effort  is  required  to  produce  this  phenomenon  in  them. 

According  to  my  experience,  the  patients  do  not  fall  when  placed  up- 
right, but  preserve  the  vertical  position,  and  can  even,  with  a  little  sup- 
port, remain  leaning  forwards.  The  muscles  of  organic  life  are  less  in- 
fluenced by  catalepsy.  Morsels,  introduced  far  back  in  the  pharynx,  are 
sometimes  swallowed  without  difficulty;  but  the  peristaltic  movements,  as 
well  as  micturition  and  defecation,  are  performed  slowly;  the  respiratory 
and  cardiac  movements  are  notably  weakened,  sometimes  scarcely  appreci- 
able, and  the  pupils  react  little  to  light.  The  disorders  of  sensation  pre- 
sent certain  interesting  peculiarities.  Ana3sthesia  and  analgesia  occur 
in  severe  cases,  and  the  patients  have  no  consciousness  of  what  has  oc- 
curred during  the  attack.  At  other  times  sensibility  is  not  abolished, 
but  there  is  absence  of  reflex  movement,  even  upon  irritation  of  the 
mucous  membranes;  sometimes  the  sole  response  consists  in  the  closure 
of  the  eyelids  upon  touching  the  conjunctiva  or  cornea. 

In  a  case,  reported  by  Jones,  the  patient  made  an  outcry  when  he  received  a  strong 
current  of  electricity,  and  afterwards  retained  the  memory  of  this  disagreeable  sensa- 
tion. Exceptionally  (as  in  Fuel's  case,  Arch.  Gen.,  1857)  hyperaesthesia  occurs  during 
the  paroxysm ;  the  slightest  touch  or  noise  will  then  cause  the  patients  to  grind  the 
teeth  or  give  vent  to  cries.  In  an  in*eresting  observation,  reported  by  Skoda  (Zeit- 
schrift der  k.  k.  Ges.  d.  Aerzte,  1852,  p.  504),  general  sensibility  was  abolished,  but  a 
lighted  taper,  rotated  rapidly  before  the  eyes,  gave  rise  to  tremor  of  the  lids,  and  strong 
odors  induced  slight  movements,  redness  of  the  cheeks,  lachrymation,  acceleration  of 
the  pulse,  and  elevation  of  the  temperature.  When  the  attack  of  catalepsy  ceased,  the 
patient  did  not  immediately  recover  the  power  of  speech,  but  was  compelled,  for 
some  time,  to  express  himself  by  gestures  or  by  writing.  It  is  to  be  remarked,  in  ad- 
dition, that  the  entire  surface  of  the  body  was  often  cold,  and  that  this  condition  of 
algidity  lasted,  on  one  occasion,  forty-eight  hours. 

The  anaesthesia  and  analgesia,  as  well  as  the  flexihilitas  cerea  (when 
the  position  of  the  limbs  is  changed  without  the  knowledge  of  the  pa- 
tient), may  even  persist  irrespective  of  the  attack,  although  voluntary 
movements  are  performed  with  perfect  freedom  in  these  cases. 

The  loss  of  conscioicsness  may  be  complete  during  the  paroxysms;  in 
other   cases,  cerebral  activity  is  not  completely  suspended,  and  the  pa- 


DISEASES    OF   THE    NERVOUS    SYSTEM.  57 

'  tients  retain  an  indistinct  idea  of  what  is  transpiring  around  them;  some 
of  them  have  a  perfect  recollection  of  surrounding  circumstances. 

I  have  examined  two  patients  with  regard  to  the  electrical  reactions 
during  cataleptic  paroxysms  ;  in  one  of  these  cases  the  reactions  to  both 
currents  were  normal  ;  in  the  other  there  was  manifest  increase  of 
electro-muscular  contractility  and  of  the  galvanic  excitability  of  the 
plexuses  and  nerve-trunks.  The  "  waxen  flexibility  "  was  very  well  mark- 
ed iu  the  latter  case,  but  the  attitude  lyroduced  by  the  faradic  stimula- 
tion of  the  extensors  and  flexors  of  the  arms,  or  by  the  galvanization  of 
the  corresponding  nerves,  disappeared  %chen  the  app>lication  of  electricity 
ceased,  and  the  hand  resumed  its  2^^€vious  position.  In  the  beginning 
we  were  able,  by  means  of  galvanization  of  the  phrenics,  to  stop  the  hic- 
cough which  formed  the  precursor  of  the  attack,  and  to  prevent  the  par- 
oxysm. At  a  later  period  the  affection  increased  in  intensity,  and  elec- 
tricity lost  its  influence. 

27ie  duration  of  the  periodical  attacks  of  catalepsy  is  as  variable  as 
their  frequency  and  intensity.  It  sometimes  terminates  after  a  few  min- 
utes, but  iu  other  cases  only  after  several  hours  or  days.  In  rare  instances 
the  disease  (as  in  Skoda's  case)  is  prolonged  for  months  with  short  interrup- 
tions. The  paroxysms  generally  occur  without  any  regularity,  and,  dur- 
ing the  intervals,  the  patients  are  either  in  good  health  or  present  various 
symptoms  of  hysteria.  The  intensity  of  the  latter  phenomena  usually  varies 
according  to  the  gravity  of  the  attacks  of  catalepsy.  The  termination  of 
the  cataleptic  paroxysm  almost  always  occurs  suddenly,  the  patients  take 
deep  respirations,  sigh,  wake  up  as  if  from  a  profound  sleep,  then  yawn 
and  stretch  their  limbs.  In  two  cases,  in  which  the  approach  of  the  par- 
oxysm was  announced  by  hiccough,  this  symptom  also  appeared  at  the 
close  of  the  attack.  When  the  attacks  have  lasted  but  a  short  time,  the 
patients  return  to  their  occupation  as  if  nothing  had  happened;  when  the 
attacks  are  more  severe  and  frequent,  the  patients  suflier,  for  a  certain 
length  of  time,  from  cephalalgia,  vertigo,  and  physical  and  mental  pros- 
tration. 

In  concluding  the  symptomatology  of  catalepsy,  I  shall  give,  with 
further  details,  the  history  of  an  interesting  case,  which  I  have  previously 
published  in  the  Wien.  Med.  Presse,  5,  1867  : 

A  nervous  girl,  nineteen  years  of  age,  after  having  been  badly  frightened,  was  soon 
seized  with  severe  general  spasms,  at  first  occurring  several  times  a  day,  then  regu- 
larly every  two  nights.  The  prodromata  of  the  attack  consisted  of  cardiac  palpita- 
tion, a  sense  of  oppression,  and  hiccough  ;  without  treatment  the  latter  symptom 
lasted  several  hours.  About  half  an  hour  before  the  beginning  of  the  paroxysm  the 
fingers  and  toes  became  congested.  Upon  examining  the  patient  shortly  after  the 
attack,  complete  anesthesia  and  analgesia  of  the  entire  surface  of  the  body  and  of  all  the 
organs  were  observed,  with  loss  of  hearing  and  smell.  If  a  hypodermic  injection  of 
0.03  of  morphine  was  given  when  the  hiccough  appeared,  this  symptom  could  be  ar- 
rested ;  ten  or  fifteen  minutes  later,  loss  of  consciousness  and  epileptiform  convul- 
sions supervened,  often  interrupted  by  hiccough,  and  terminating  in  a  cataleptic  con- 
dition (with  very  marked  '''' tcaxen  flexibility'''').  These  attacks  terminated,  although 
not  invariably,  in  a  very  peculiar  delirium,  during  which  the  patient,  with  her  eyes 
closed,  conversed  with  her  father,  who  had  been  dead  several  months.  (She  often 
clasped  my  hand,  mistaking  it  for  her  father's.)  She  related  to  him  (mentioning 
names,  dates,  and  figures),  and  often  in  an  ironical  tone,  the  family  affairs  which  had 
transpired  since  his  death.  From  time  to  time  these  strange  dreams  were  interrupted 
by  painful  scenes  ;  the  patient  uttered  terrible  cries,  and  imagined  herself  in  the  midst 
of  a  fire  or  surrounded  by  enemies.  Hiccough  and  slight  spasms  occurred  towards  the 
close  of  the  attack,  and  the  patient  then  awoke,  and  displayed  great  embarrassment 
when  informed  of  the  remarks  she  had  mad«. 

The  anaesthesia  persisted  for  twelve  to  twenty-four  hours  after  the  attack.      When. 


58  CLINICAL   TEEÄTISE    ON 

the  patient  was  not  permitted  to  use  her  eyes,  or  wlien  the  lids  were  closed  on  account  of 
the  frequent  bilateral  spasm  of  the  orbicular  musdes,  she  was  forced  to  remain  absolutely 
guiet,  aud  was  only  able  to  perform  a  voluntary  movement  when  she  could  see  her  own 
limbs.  The  ' '  waxen  flexibility  "  persisted  in  severe  paroxysms,  even  after  the  return  of 
motor  power.  I'aradic  and  galvanic  exploration,  after  the  attack,  gave  the  following 
results  :  preservation  of  electro-muscular  contractility  and  of  the  excitability  of  the 
nerves,  abolition  of  electro  cutaneous  and  electro-muscular  sensibility ;  at  times,  how- 
ever, the  prolonged  application  of  the  wire-brush  with  a  strong  current  produced  a 
sensation  of  pricking  aud  burning. 

Large  doses  of  morphine,  administered  subcutaneously,  gave  good  results  in  the 
beginning  ;  but,  after  a  while,  they  failed  to  produce  any  effect,  and  it  became  neces- 
sary to  administer  chloroform,  followed  immediately  by  a  subcutaneous  injection  of 
morphine.  In  order  to  stimulate  the  nervous  system  and  the  organic  functions,  I  pre- 
scribed the  arseniate  of  iron  (in  doses  of  0.0U05),  mild  hydrotherapeutic  measures, 
cool  baths,  and  a  trip  to  the  country.  After  having  continued  six  months,  the  attacks 
diminished  in  frequency  and  intensity,  and  disappeared  during  the  winter,  but  re- 
turned again  in  spring,  after  emotional  excitement.  In  addition  to  the  measures  pre- 
viously mentioned,  subcutaneous  injections  of  curare  were  made  for  several  weeks, 
without  marked  benefit.  (.005-.  006  of  a  solution,  composed  of  0.07  to  four  grammes 
of  water,  with  two  drops  of  absolute  alcohol,  were  administered  every  two  days. )  The 
patient  recovered,  after  the  lapse  of  several  months,  during  her  residence  in  the  coun- 
try and  under  the  influence  of  treatment  with  baths.  The  menses,  which  had  been 
suppressed  for  a  year,  were  slowly  re-established,  the  catalepsy  disappeared,  and  the 
patient  was  restored  to  excellent  health. 


Etiology. 

The  large  majority  of  cases  of  catalepsy  originate  in  hysterical  pa- 
tients. As  Puel  has  shown,  in  his  prize  essay  on  catalepsy  (Mcmoires 
de  I'Acad.  de  Med.,  Paris,  1856,  T.  XX.,  p.  409-526),  and  also  accord- 
ing to  Georget,  Favrot,  etc.,  catalepsy  almost  always  occurs  in  females  in 
whom  careful  e.xamination  will  reveal  signs  of  hysteria.  This  holds  good 
of  the  three  examples  which  came  under  my  own  observation.  In  the 
majority  of  cases  we  are  able  to  discover  the  motor  and  sensory  disor- 
ders and  the  electrical  reactions  characteristic  of  hysteria.  Catalepsy 
usually  supervenes  upon  h^^sterical  paroxysms  of  old  date  ;  in  rarer 
instances  it  precedes  the  development  of  such  phenomena  (Georget). 
During  the  period  of  the  epidemics  of  hysteria  (Loudun,  Louviers, 
Cologne)  the  hysterical  convulsions  were  intimately  associated  with 
cases  of  catalepsy.  As  we  have  previously  stated,  the  condition  which 
Lasfegue  denominates  as  temporary  catalepsy  may  be  produced  at  times  in 
hysterical  patients  by  covering  their  eyes  with  the  hand  or  with  a  cloth. 
Finally,  it  has  been  shown  that  the  chief  causes  of  hysteria  (emotional 
excitement,  suppression  of  the  menses,  unrequited  love)  also  predispose 
to  the  production  of  catalepsy. 

In  addition  to  violent  emotions,  the  appearance  of  catalepsy  is  favored 
by  over-excitement  of  the  intellect  and  by  religions  exaltation,  when  a 
morbid  psychical  susceptibility  coexists.  This  also  holds  good  of  the 
causes  which  lead  to  a  co7i(lition  of  exhaustion  of  the  nervous  system, 
such  as  masturbation,  chlorosis,  and  certain  forms  of  phthisis.  We  also 
observe  the  development  of  cataleptic  rigidity  of  the  muscles,  combined 
with  anaesthesia,  analgesia,  and  abolition  of  the  functions  of  special  sense, 
in  chorea  magna,  and  in  psychical  affections  associated  with  depression 
or  exaltation  (melancholia  attonita,  mania,  ecstasy).  I  have  observed 
partial  catalepsy  in  an  insane  patient  suffering  from  progressive  cerebro- 
spi?ial 2^(ifalysis  /  Meissner  also  reports  a  similar  observation. 

The  facts  which  Ave  quoted  in  the  beginning  of  this   article  serve  to 


DISEASES    OF   THE   NERVOUS    SYSTEM.  59 

'  show  that  the  symptoms  of  catalepsy  may  be  present  in  degenerations  of 
the  brain  /  partial  catalepsy  is  also  observed  after  typhoid  fever,  with 
severe  cerebral  symptoms,  and  in  meningitis  (as  I  have  often  had  occa- 
sion to  notice).  According  to  Medicus  and  Eisenmann,  certain  cases  of 
prolonged  intermittent  fever  may  be  combined  with  cataleptic  attacks.  ^ 
The  administration  of  narcotics  and  inhalations  of  ether  and  chloroform 
are  also  followed,  at  times,  by  symptoms  of  temporary  catalepsy. 

Almost  all  cases  of  the  disease  are  found  in  young  people.  The  periods 
of  puberty  and  early  menstruation  and  pregnancy  furnish  the  most 
favorable  causes  for  the  development  of  cataleptic  seizures  in  predisposed 
individuals.  Cases  are  of  rare  occurrence  at  a  more  advanced  age,  and 
are  then  due  to  intense  excitement.  The  female  sex,  which  furnishes 
such  a  large  contingent  to  hysteria,  is  also  more  subject  to  catalepsy. 
Nevertheless,  the  male  sex  does  not  entirely  escape. 

In  Jones's  case,  reported  above,  the  patient  was  a  man  of  sixty,  previously  healthy, 
with  the  exception  of  a  slight  neuropathic  tendency  ;  he  was  affected  with  the  cataleptic 
symptoms,  after  suddenly  receiving  the  news  of  the  death  of  his  wife  ;  the  paroxysms 
disappeared  at  the  end  of  eleven  days.  In  a  case  coming  under  my  own  observation, 
the  disease  also  occurred  in  a  man,  ast.  sixty  years.  In  the  Vienna  General  Hospital  I 
had  under  my  charge  a  boy,  set.  twelve  years,  who,  after  having  been  greatly  excited,  suf- 
fered from  headache  and  convulsions,  with  incomplete  loss  of  consciousness.  During 
these  seizures,  which  lasted  from  eight  to  ten  minutes,  the  upper  limbs  were  in  a  con,' 
dition  of  "■  flembilitas  cerea ;  "  the  attacks  occurred  several  times  a  week,  and  almost 
always  presented  the  same  characteristics ;  they  were  never  followed  by  sleep. 
After  the  administration  of  oxide  of  zinc  (1.50  grammes  in  six  doses  during  the  day),  the 
paroxysms  soon  disappeared,  and  remained  absent  for  a  month,  when  the  patient  was 
removed  from  the  hospital. 


The  Nature  of  Catalepsy. 

The  recent  results  of  experimentation,  and  the  advances  in  the  histo- 
logical data  concerning  the  relations  of  the  various  parts  of  the  nervous 
system,  enable  us  to  understand  more  fully  the  peculiarities  of  this  inter- 
mittent neurosis  of  the  cerebro-spinal  system.  As  Schiff  first  demon- 
strated in  rabbits,  and  Goltz,  later,  in  frogs,  animals  deprived  of  their 
cerebral  hemispheres,  including  the  motor  ganglia,  retain  the  most  ab- 
normal positions  in  which  they  are  placed,  although  their  joints  remain 
flexible.  If  a  part  of  the  body  is  mechanically  irritated,  the  rabbit  will 
jump  forwards  with  precipitate  movements,  and,  when  it  is  arrested  by 
some  obstacle,  it  remains  immovable  in  the  position  which  it  had  last 
assumed. 

Thus,  although  by  removing,  in  animals,  the  fibres  of  origin  of  the 
foot  of  the  cerebral  peduncle,  contained  in  the  corpus  striatum  and  len- 
ticular nucleus,  and  the  radiations  which  these  organs  send  into  the  ante- 
rior lobes,  voluntary  motion  is  abolished,  reflex  impulses  may,  neverthe- 
less, be  transmitted  from  the  optic  thalamus  and  tubercula  quadrigemina 
to  the  anterior  roots,  through  the  tegmentum  of  the  peduncle  (Mey- 
nert). 

In  the  same  manner,  in  the  cataleptic  paroxysms  in  man,  as  well  as 
in  hysteria,  melancholia,  insanity,  and  other  affections,  there  is  an  abnor- 
mal resistance  to  transmission  in  the  motor  ganglia  and  in  the  corona 
radiata,  which  start  from  the  cortex  and  transmit  impulses  to  the  anterior 
roots.  The  stimulation  of  the  muscles  is  thus  reduced  to  a  minimum;  the 
latter,  therefore,  offer  no  resistance  to  the  reflex  stimuli  which  may  reach 


60  CLINICAL   TREATISE    ON 

them  through  the  tegmentum  pedunculi,  and  it  is  in  this  manner  that  the 
most  marked  actions  are  produced. 

The  data  furnished  by  pathological  anatomy  also  favor  this  interpreta- 
tion. The  autopsies  performed  in  man,  although  leaving  much  to  be  desir- 
ed, have  demonstrated  the  existence  of  changes  in  the  domain  of  the  corpus 
striatum  and  in  the  cortical  zone  of  the  anterior  lobes.  In  the  first  case 
which  I  observed,  the  retardation  of  motor  impulses,  even  advancing  to 
complete  suspension,  could  be  noted  under  the  eyes  of  the  observer;  it 
was  only  then  that  the  waxen  flexibility  occurred.  In  my  second  case 
the  latter  symptom  remained  permanent,  and  the  retardation  of  the  motor 
impulses  was  very  evident  from  the  manifest  heaviness  and  slowness  of 
the  movements  of  the  patient;  during  walking  the  reflex  acts  assumed 
the  ascendancy,  so  that  the  patient,  despite  himself,  walked  more  and 
more  rapidly,  until  some  obstruction  compelled  him  to  stop.  Thus,  while 
the  direct  action  of  stimuli  upon  the  skin,  or  (as  in  one  of  my  cases)  the 
electrical  irritation  of  the  muscles  or  nerves,  produced  no  reflex,  and  al- 
though the  limbs  did  not  retain  the  positions  which  were  artificially  given 
to  them,  nevertheless  the  stimulus  communicated  by  passive  movements 
to  the  sensory  nerves  of  the  bones  and  articulations  could  be  reflected  to 
certain  groups  of  muscles.  According  to  the  progress  of  the  recovery, 
this  abnormal  resistance  to  the  nerve  current  diminishes  in  the  central 
organs,  and,  as  the  motor  innervation  reassumes  its  ascendancy,  the  pre- 
ponderating action  of  the  reflex  movements  is  abolished. 

I  had  occasion  to  observe,  in  my  second  patient,  that  the  power  of  the 
cerebral  activity  could  be  temporarily  recovered,  when  stimulated  by 
necessity.  I  accidentally  entered  his  house  as  his  wife  was  being  threat- 
ened by  a  drunken  neighbor.  His  wife  fled,  pursued  by  the  drunkard;  the 
patient,  seeing  her  danger,  rose  from  his  couch,  ran  towards  the  ruffian, 
and,  raising  his  right  hand,  called  out  loudly  to  him.  After  I  had  suc- 
ceeded in  re-establishing  quiet,  I  found  the  patient  stretched  upon  the 
bed  and  evidently  exhausted;  he  had  fallen  back  into  the  same  condition 
in  which  he  had  been  previous  to  the  scene.  He  had  succeeded,  in  the 
face  of  this  urgent  necessity,  in  surmounting  the  obstacles  to  which  the 
actions  of  his  nervous  system  were  subject. 


Diagnosis  and  Prognosis. 

When  the  patients  are  seized  with  the  cataleptic  paroxysm,  while 
engaged  in  some  occupation,  they  remain  like  statues  in  the  position 
which  they  had  assumed  at  the  time,  and  the  diagnosis  can  be  made  at 
the  first  glance.  The  invasion  of  catalepsy  is  less  significant  and  more 
insidious  when  it  affects  the  patients  while  lying  in  bed.  It  then  becomes 
necessary,  while  relying  upon  the  symptoms  of  some  pre-existing  affection 
(hysteria,  chorea  magna,  psychical  disorders)  and  upon  the  appearance  of 
tonic  spasms,  to  undertake  a  more  careful  examination  of  the  motor  and 
sensory  functions,  and  to  look  for  the  characteristic  flexibility. 

We  will  find,  on  looking  over  medical  literature,  that  many  cases  have 
been  regarded  as  catalepsy  upon  very  slight  grounds.  In  many  instances 
which  have  been  regarded  as  such  (catalepsy  without  flexibility  was 
called  catechus,  and  the  forms  with  more  continuous  symptoms,  lethargus) 
it  is  evident  that  the  phenomena  were  merely  those  of  hysteria,  with 
predominance  of  tonic  spasms,  loss  of  insensibility,  and  lethargy.  It  is 
clear,  from  our  description  of  the  clinical  history,  that  each  of  the  dis- 


DISEASES    OF   THE    NEKVOUS    SYSTEM.  61 

orders  regarded  as  characteristic  of  catalepsy  (disorders  of  the  sensorium, 
perceptions,  and  reflex  actions),  as  well  as  the  '''^  loaxen  flexibility''''  may 
be  absent  in  some  cases,  while  the  other  symptoms  are  more  or  less 
marked. 

In  such  cases  the  diagnosis  of  catalepsy  is  often  very  uncertain,  and 
may  depend  upon  the  personal  bias  of  the  observer. 

If  we  wish  to  assign  to  catalepsy  a  distinct  place  in  the  nosology,  I 
think  the  chief  stress  must  be  laid  upon  the  existence  of  the  "  waxen 
flexihilityy  This  is  the  most  characteristic  symptom  of  the  affection, 
and  belongs  to  no  other  disease.  If  we  do  not  impose  this  rigorous  cri- 
terion, we  are  brought  in  contact  with  various  conditions,  which  will 
introduce  confusion  into  the  pathology  of  the  affection,  and  embarrass 
investigation. 

Simulation  of  catalepsy  is  very  rare.  It  is  not  easy  to  remain  for  some 
minutes  in  an  abnormal  attitude,  as  can  be  seen  in  those  taking  part  in 
tableaux,  in  which  the  actors  show  by  their  frequent  starts  that  they  can 
with  difficulty  sustain  their  rules.  Energetic  electrization  of  the  skin, 
mucous  membranes,  and  nerves  will,  however,  cut  short  any  attempts  at 
deceit;  the  behavior  of  the  individuals  before  and  after  the  attack  must 
also  be  taken  into  consideration.  The  case  of  cataleptic  lethargy,  pub- 
lished by  Macedo  (II  Siglo  Medico,  June,  18G4),  and  which  recovered  upon 
the  application  of  an  induced  current  to  the  neck,  face,  temples,  and  sym- 
pathetic nerve,  after  three  seances  of  five  minutes'  duration,  is,  to  say  the 
least,  suspicious. 

From  &  prognostic  point  of  view,  simple  catalepsy  is  not  a  serious  af- 
fection, and  usually  disappears  spontaneously  at  the  end  of  a  certain  time. 
When  it  accompanies  hysterical  or  psychical  affections,  it  is  generally  a  se- 
vere complication;  and,  when  it  appears  in  the  advanced  periods  of  the  dis- 
ease, it  testifies  to  a  more  marked  invasion  of  the  nervous  system,  and  is 
often  combined  with  symptoms  of  ecstasy,  somnambulism,  and  hystero- 
epilepsy.  When  the  neurosis  lasts  several  months,  it  may  either  be  in- 
termittent or  merely  present  (as  in  Skoda's  case)  exacerbations  and  remis- 
sions; it  then  becomes  necessary  to  keep  up  the  strength  of  the  patient 
and  to  resort  to  artificial  nourishment.  The  improvement  in  the  temper- 
ature and  pulse  and  the  return  of  olfactory  and  gustatory  sensibility  are 
the  first  indications  of  a  return  to  a  condition  of  health.  As  we  have  seen 
in  the  observation  reported  at  the  beginning  of  this  article,  the  patients 
may  die  from  antemia  and  inanition. 

Judging  from  the  facts  which  I  have  observed,  we  should  regard  the 
integrity  of  motion  and  sensation  during  the  intervals  of  the  attacks  as  a 
favorable  prognostic  sign.  Even  when  the  anaesthesia  and  analgesia  re- 
turn during  the  paroxysms,  their  momentary  disappearance  nevertheless 
indicates  that  improvement  is  progressing.  The  return  of  appetite,  the 
restoration  of  the  menses,  and  calmness  of  mind  may  be  interpreted  as  in- 
dications of  convalescence.  We  not  infrequently  notice,  towards  the 
close  of  the  disease,  that  the  cataleptic  attacks  and  the  deliriums  become 
more  frequent  and  severe,  the  other  signs  of  improvement  continuing, 
however,  during  the  intervals. 


Treatment. 

As  the  cataleptic  paroxysms  are  usually  manifestations  of  hysteria  or 
of  some  mental  disorder,  we  should  direct  all  our  attention  to  the  primary 


62  CLINICAL   TREATISE   ON 

disease.  If  the  latter  improves,  the  cataleptic  symptoms  will  also  grad- 
ually disappear.  The  best  results  are  obtained  by  an  appropriate  symp- 
tomatic and  moral  treatment.  Tonics,  the  antispasmodics  (to  which  we 
have  referred  in  the  chapter  on  hysteria),  mild  hydrotherapeutic  measures, 
the  neutral  mineral  waters,  and  a  trip  to  the  country  or  to  the  mountains, 
in  addition  to  methodical  education  of  the  will,  constitute  the  surest  means 
of  producing  recovery.  In  the  chronic  forms  we  must  pay  especial  at- 
tention to  alimentation,  and,  if  necessary,  use  the  oesophageal  sound.  In 
certain  cases  we  are  able  to  produce  movements  of  deglutition  by  placing 
the  food  at  the  base  of  the  tongue. 

Calvi  succeeded  in  relieving  the  cataleptic  stiffness,  in  one  case,  by  an 
injection  of  a  solution  of  tartar  emetic  into  the  brachial  vein.  If  the 
symptoms  of  catalepsy  occur  after  intermittent  fever,  we  may  give  large 
doses  of  quinine.  I  have  twice  employed  the  continuous  current  (from 
the  head  and  vertebral  column  to  the  nerves)  for  a  certain  length  of  time, 
but  I  observed  no  appreciable  effect  upon  the  course  of  the  disease.  I 
have  also  employed,  but  without  succese,  hypodermic  injections  of  curare. 
We  may,  by  accident,  administer  a  new  remedy,  at  a  time  when  the  dis- 
ease is  spontaneously  improving,  and  we  must,  therefore,  not  exaggerate 
the  value  of  the  drugs  to  which  we  have  resorted. 


DISEASES    OF   THE    NEKVOUS    SYSTEM.  63 


CHAPTER  XXIX. 

KPILEPSY. 

Pathological  Anatomy  and  Experimental  Investigations. 

ScHROEDER  VAN  DER  KoLK  first  pointed  out  the  changes  occurring  in 
the  nervous  system  in  epilepsy  (Bau  und  Functionen  d.  Med.  spin.  u. 
oblong.,  nebst  Ursache  u.  Behandlung  d.  Epilepsie,  1859).  He  found  con- 
siderable  dilatation  of  the  vessels,  especially  in  the  jyosterior  hcdf  of  the 
medulla  oblongata,  extending  from  the  fourth  ventricle  to  the  hypoglossal 
and  pneumogastric  nerves  or  olivary  bodies,  whose  roots  receive  the  larger 
part  of  the  vessels  of  the  medulla.  Kroon  has  observed  in  epileptics 
an  abnormal  and  unsymmetrical  development  of  the  olivary  bodies,  with 
asymmetry  of  the  medulla.  Solbrig  found,  in  nine  cases  of  epilepsy,  a 
constriction  of  the  sjnnal  canal  from  hypertrophy  of  the  jugular  process 
of  the  occipital  bone  and  of  the  posterior  arches  of  the  atlas  and  axis,  with 
secondary  atrophy  of  the  medulla  oblongata,  the  latter  being  regarded 
as  the  point  of  departure  of  the  epileptic  attacks. 

Lelut  and  Delasiauve  have  called  attention  to  sclerosis  of  the  Am7non^s 
ham,  a  lesion  which  Meynert  has  more  recently  investigated.  Accord- 
ing to  the  latter  author,  this  lesion  is  merely  secondary,  and  the  epilepsy 
is  due  to  changes  in  parts  remote  from  this  point.  A  circumstance  which 
appears  to  substantiate  the  theory  of  the  secondary  character  of  this  local- 
ized affection  of  the  cortical  region,  is  found  in  the  fact  that,  in  Kussmaul's 
experiments  upon  animals,  removal  of  the  Amnion's  horn  had  no  effect 
either  upon  the  production  or  upon  the  intensity  of  the  general  convul- 
sions. Nothnagel  has  recently  produced  lesions  of  the  cornu  Ammonis  (by 
incision  or  injection  of  chromic  acid),  which  resulted  in  no  disorders  of  this 
nature,  although  the  animals  succumbed  rapidly,  as  a  rule,  to  meningitis. 

It  is  evident  that  pathological  anatomy  furnishes  us  with  very  few  data 
with  regard  to  the  nature  of  epilepsy,  and  more  importance  must  there- 
fore be  attached  to  the  experimental  investigations  which  have  been  made 
in  this  direction.  These  experiments  have  been  performed  under  the  fol- 
lowing different  conditions  :  compression  of  vessels  more  or  less  remote 
from  the  brain;  arterial  anaemia  or  venous  hyperemia,  and,  as  a  conse- 
quence, epileptiform  convulsions;  general  convulsions,  produced  by  direct 
irritation  of  the  surface  of  the  pons  and  medulla;  epileptiform  attacks, 
from  lesion  of  the  cord  or  of  certain  spinal  nerves  and  from  traumatic  or 
electrical  irritation  of  the  encephalon;  finally,  ii'ritation  of  the  cord,  by 
means  of  toxic  substances,  rendering  the  animals  epileptic. 

The  first  experiments  which  opened  the  way  for  the  study  of  epilepsy 
were  performed  by  Astley  Cooper  ;  he  demonstrated  upon  rabbits  (Guy's 
Hosp.  Rep.,  1836,  I.,  p.  465)  that  ligature  of  both  carotids  and  compres- 
sion of  the  vertebrals  gave  rise  to  loss  of  consciousness,  suspe7ision  of  the 
respiratory  moveiments,  a7id  convidsive  attacks.  If  the  compression  of 
the  arteries  was  stopped,  the  animal  recovered  in   a   few  minutes  ;  when 


64  CLINICAL   TREATISE    ON" 

compression  was  again  made  (about  six  times  in  forty-eight  hours),  the 
same  symptoms  were  reproduced. 

Travers  and  Marshall-Hall  noticed,  for  the  first  time,  the  similarity  of 
the  convulsions  which  rapidly  occurred  in  man  and  warm-blooded  animals 
after  excessive  hjemorrhage,  to  the  convulsions  of  epilepsy  and  eclampsia. 
The  latter  author  placed  the  origin  of  these  phenomena  in  the  cord. 

Twenty  years  later,  Kussmaul  and  Tenner  (Moleschott's  Untersuch- 
ungen, 1857,  Bd.  IL,  p.  248)  repeated  these  experiments  more  cautiously 
and  rigorously  upon  rabbits,  dogs,  and  cats.  In  vigorous  animals,  rapid 
and  abundant  hjemorrhages  produced  epileptiform  convulsions,  similar  to 
those  due  to  ligature  or  compression  of  the  carotids  and  vertebrals.  The 
convulsions  were  not  produced  if  one  of  these  four  arteries  remained  per- 
meable. Other  experiments,  made  by  Kussmaul  and  Tenner,  upon  com- 
pression of  both  carotids,  which  were  confirmed  at  a  later  period  by 
Wachsmuth  (Gutting,  gel.  Anz.,  1857,  p.  187),  and  a  certain  number  of 
cases  of  ligature  of  the  carotid  in  man,  have  sliown  that,  under  such  cir- 
cumstances, all  the  symptoms  of  an  attack  of  epilepsy  may  appear. 

By  ligaturing  both  subclavian  arteries  and  the  arch  of  the  aorta  in 
rabbits,  and  by  bleeding  the  animals  after  transverse  section  of  the  cord, 
it  has  been  found  that  interruption  of  the  supply  of  blood  to  the  cord 
never  produces  strong  convulsions  (as  Mar^iall  Hall  believed),  but  merely 
paralysis  or  slight  tremulous  movements. 

Kussmaul  and  Tenner  have  shown,  in  a  series  of  experiments,  by  pla- 
cing a  watch-glass  in  the  opening  of  a  trephined  skull,  without  allowing 
the  air  to  enter  (Donder's  plan),  that  compression  of  the  carotids  causes 
capillary  ancemia  and  venous  Jiypermmia  of  the  brain  and  meninges ; 
when  the  blood  is  again  permitted  to  freely  transverse  the  vessels  of 
the  neck,  the  brain  assumes  a  rosy  red  hue,  and  a  very  marked,  m,omen- 
tary  cerebral  hyjyercemia  occurs,  lohich  is  unattended  by  convidsions. 
Raising  the  vault  of  the  skull,  or  allowing  the  ■escape  of  the  cerebro-spinal 
fluid,  had  no  effect  upon  the  convulsions  produced  in  the  experiments 
which  we  have  mentioned,  and  consequently  they  were  not  due  to  the 
cessation  of  the  mechanical  pressure  upon  the  brain,  but  to  the  interrup- 
tion of  the  supply  of  blood  and  to  the  sudden  arrest  of  nutrition  thus 
produced. 

Other  experiments  have  been  performed  in  order  to  locate  more  ex- 
actly in  the  brain  the  centre  of  convulsive  movements  (various  parts  of 
the  brain  were  carefully  removed,  after  compression  of  the  correspond- 
ing vessels).  These  experiments  showed  that  this  centre  is  situated  in 
the  motor  regions  behind  the  optic  thalamus  {cerebral  peduncles,  tuber- 
cula  quadrigemina,  etc.),  which  were  irritated  by  the  sudden  interruption 
of  their  nutrition.  In  a  case  of  ligature  of  both  vertebrals  and  one  caro- 
tid, epileptiform  attacks  were  produced  by  electrical  irritation  of  the 
sympathetic  nerve  upon  the  side  of  the  permeable  carotid. 

Landois  has  obtained  interesting  data  (Centralbl.  f.  d.  med.  "Wiss., 
1867,  10)  with  regard  to  the  influence  of  venous  hypercemia  of  the  brain 
and  cord  upon  the  appearance  of  epileptiform  convulsions.  Upon  mo- 
mentarily obliterating  the  superior  vena  cava  in  rabbits,  he  observed  a 
diminution  in  the  number  of  pulsations;  venous  congestion  of  the  parts 
situated  between  the  tubercula  quadrigemina  and  the  cord  caused  com- 
plete arrest  of  the  heart,  as  in  asphyxia,  with  epileptiform  convulsions. 
Herrmann  has  also  produced  epileptiform  convulsions  in  rabbits,  by  simul- 
taneous ligature  of  the  superior  and  inferior  venne  cavne.  These  experi- 
ments substantiate  those  made  by  Schroeder  van  der  Kolk. 


DISEASES    OF   THE    NERVOUS    SYSTEM.  65 

Nothnagel  has  experimentally  demonstrated  the  role  played  by  the 
pons  varolii  and  medxdla  oblongata  in  general  convidsions  (Virch.  Arch., 
XL  Bd.,  1.  H.,  1868),  and,  by  irritating  the  brain  of  animals  with  a  needle, 
he  has  endeavored  to  locate  the  true  boundaries  of  the  "  co7ividsive  centred 

Upon  irritating  the  floor  of  the  fourth  ventricle,  the  lower  limit  is 
found  to  be  the  upper  part  of  the  aim  einer eoi  ;  the  upper  limit  is  situated 
above  the  locus  coeruleus  /  the  inner  limit  is  formed  by  the  upper  border 
of  the  eminentia  teres  y  the  outer  boundary  is  more  difficult  to  determine, 
and  appears  to  be  formed  above,  by  the  lateral  border  of  the  locus  coeru- 
leus, and,  below,  by  the  acoustic  tubercle  and  \\\q  fascic.  gracilis. 

The  depth  of  the  puncture  is  immaterial.  We  cannot  believe  that  the 
irritation  of  a  small  number  of  motor  fibres  is  the  cause  of  the  convulsions, 
since  this  would  be  insufficient  to  produce  general  convulsions;  the  latter 
must,  therefore,  be  reflex  in  their  nature.  Since,  after  section  of  the  me- 
dulla oblongata,  the  spasms  are  not  produced  except  upon  irritation  of 
the  surface  which  unites  the  lower  border  of  the  pons  with  the  upper 
border  of  the  acoustic  tubercle,  it  follows  that  the  convulsive  centre,  which 
transmits  the  stimulation  of  the  sensory  to  the  motor  fibres,  is  not  situ- 
ated in  the  medulla  oblongata,  but  in  the  pons  varolii.  This  agrees  with 
the  experiments  of  Schiff  and  Deiters  and  with  certain  pathological  ob- 
servations (haemorrhages  into  the  pons). 

IVie  relations  of  lesions  of  the  cord  or  of  certain  spinal  nerves  to 
epilepsy  were  noticed,  for  the  first  time,  by  Brown-Sequard,  who  has 
cleared  up  this  question  by  numerous  investigations  (Soc.  biol.,  1850; 
Arch,  gen.,  185G;  Lancet,  1861;  Bull,  de  I'Acad.  de  Med.  de  Paris,  Jan., 
1869).  These  experiments  were  most  successful  in  guinea-pigs;  after 
making  a  transverse  incision  through  one  of  the  lateral  halves  or  through 
the  posterior  part  of  the  cord,  in  the  dorsal  or  lumbar  regions,  it  was 
found  that  epileptiform  spasms  developed  during  the  next  three  or  four 
weeks,  when  the  skin  of  the  lateral  portion  of  the  neck  or  face  (epilepto- 
genic zone)  was  pinched.  At  a  later  period  the  convulsions  also  appeared 
spontaneously.  The  same  results  are  obtained  by  incising  the  cord  very 
near  the  medulla,  or  by  cutting  the  sciatic  nerve  near  its  origin.  But 
epilepsy  will  not  result  if  the  cord  has  been  cut  immediately  above  the 
point  of  emergence  of  the  roots  of  the  sciatic  nerve.  Convulsions  may 
be  experimentally  produced  in  guinea-pigs,  even  after  the  removal  of  the 
cerebrum,  pons,  and  cerebellum,  by  keeping  up  artificial  respiration.  In 
one  case  the  young  of  one  of  the  animals,  which  had  been  rendered 
epileptic,  suffered  from  spontaneous  attacks  of  epilepsy. 

Westphal  has  shown  (Ber.  Klin.  Wschr.,  38,  1871)  that,  in  gninea-pigs, 
blows  \ipon  the  head  may  immediately  give  rise  to  the  prodxiction  of 
epileptiform  attacks,  and  that,  in  these  cases,  the  convulsions  will  result, 
even  after  several  weeks,  from  pinching  the  skin  of  the  epileptogenic 
zone.  Transverse  sections  of  the  cervical  cord  and  of  the  medulla  ob- 
longata showed,  as  constant  lesions,  small  haemorrhages,  attaining  the 
size  of  a  pin's  head,  in  the  white  and  gray  substances.  The  lesions  often 
extended  downwards  into  the  dorsal  region,  and  there  was  usually  a 
haemorrhagic  effusion  into  the  cavity  of  the  spinal  dura  mater.  In  rare 
cases  a  slight  haemorrhage  was  observed  at  the  base  of  the  brain.  Ac- 
cording to  Ferrier's  recent  researches,  epileptiform  convulsions  may  be 
produced  upon  the  opposite  side  of  the  body,  by  passing  strong  induced 
currents  through  one  of  the  cerebral  hemispheres.  An  analogous  obser- 
vation has  been  made  by  Bartholow;  in  a  woman,  whose  left  cerebral 
hemisphere  was  exposed  by  a  carcinoma  of  the  skull,  the  application  of 
Vol.  II.— 5 


66  CLINICAL    TREATISE    ON 

an  induced  current  to  the  brain  gave  rise  to  epileptiform  convulsions  upon 
the  opposite  side  of  the  body. 

According  to  Magnan  (Etudes  experimentales  sur  I'Alcoolisme,  Paris, 
1871),  injections  of  absinthe  in  dogs  give  rise  to  epilepsy ,  folloioed  by 
stiq^or.  Autopsies  iipon  these  animals  showed  intense  hyperajmia  of  the 
medulla  oblongata  and  a  diffuse  rose  color  and  strong  vascular  injection 
in  thin  sections  of  the  brain  and  cord. 

In  conclusion,  we  may  add  that  Brown-Sequard  has  observed  contrac- 
tion of  the  vessels  of  the  cerebral  jna  mater  in  epileptic  animals.  The 
investigations  of  Loven,  Nothnagel,  and  others  have  shown  that  irritation 
of  the  peripheral  nerves  acts  in  the  same  manner  upon  the  cerebral  vessels. 
This  explains  the  appearance  of  epileptic  seizures  under  the  influence  of 
peripheral  irritations. 


Symptomatology. 

Typical  epilepsy  is  characterized  by  three  categories  of  phenomena,  viz., 
disorders  of  intelligence,  of  sensation,  and  of  motion,  which,  in  the  severe 
cases,  appear  suddenly  and  simultaneously,  and,  in  less  severe  forms, 
follow  each  other  in  a  certain  order,  while  the  lightest  attacks  (petit  mal) 
only  include  one  order  of  symptoms.  The  disorders  of  these  various 
functions  are  usually  preceded  by  slight  symptoms  of  peripheral  irritation; 
these  constitute  the  aura,  or  first  peripheral  manifestation  of  the  vascular 
spasm  which  is  beginning  in  the  central  parts,  and  the  nature  of  which 
we  shall  discuss  further  on.  According  to  the  variations  in  this  vascular 
spasm,  the  aura  may  alternately  affect  the  sensorial  functions,  sensation 
or  motion  (vertigo,  feeling  of  anguish,  illusions  of  the  senses,  painful 
sensations,  spasms,  etc.).  The  aura  often  presents  an  ascending  course, 
which  may  be  explained  by  the  dissemination  of  the  central  irritation 
from  below  upwards;  the  possibility  of  sometimes  interrupting  the  attack 
by  the  ligature  of  a  limb,  may  be  interpreted  as  the  effect  of  counter- 
irritation. 

When  the  attack  proper  begins,  the  patient  falls  unconscious,  giving 
utterance  to  a  sharp  cry  (reflex  spasm  of  the  muscles  of  phonation  and 
respiration),  and  the  face  is  almost  always  pallid;  then  follows  a  tonic  spasm 
of  the  abdominal  walls  and  inspiratory  muscles,  which  lasts  from  ten 
seconds  to  one  minute,  and  is  replaced  by  clonic  convulsions  involving 
the  limbs  and  trunk.  The  head  is  drawn  backwards,  the  muscles  of  the 
haggard  and  livid  face  are  in  a  condition  of  spasmodic  contraction,  the 
gaze  is  fixed,  froth  appears  at  the  mouth,  the  teeth  are  ground  together, 
the  tongue  is  bitten,  the  carotids  are  distended,  and  the  respirations  cease; 
from  time  to  time  rapid  muscular  contractions  occur;  the  thumb  is  flexed 
strongly  upon  the  palm,  the  pulse  is  small,  consciousness  and  reflex  action 
are  lost.  These  are  the  usual  features  of  the  attack ;  partial  sweats, 
vomiting,  meteorism,  involuntary  emission  of  urine  and  fceces,  and  erections 
are  observed  more  or  less  frequently. 

After  the  convulsive  stage  has  lasted  from  two  to  five  minutes,  these 
tumultuous  symptoms  gradually  subside.  The  spasmodic  movements  dis- 
appear, relaxation  of  all  the  limbs  occurs,  the  respirations  become  less 
labored,  the  cyanosis  passes  away,  the  pulse  becomes  stronger,  and  con- 
sciousness returns,  or  the  patient  falls  into  a  profound  sleep,  interrupted 
by  delirium  and  frequent  starts.  The  paroxysms  are  usually  followed, 
for  a  certain  length  of  time,  by  exhaustion,  disordered  ideas,  weakness  of 


DISEASES    OF   THE    NERVOUS    SYSTEM.  67 

memory,  and  malaise,  more  rarely  by  dimness  of  vision,  paresis,  or  hemi- 
paresis. 

The  cadaverous  pallor  of  the  onset  of  the  attack,  which  forms  so  im- 
portant a  sign  in  the  diagnosis  of  epilepsy,  is  regarded  as  a  very  frequent 
symptom  by  Trousseau,  Brown-Sequard,  Sieveking,  and  Radcliffe,  while 
liussel-Reynolds  (Epilepsy  :  its  Symptoms,  Treatment,  and  Relations,  etc., 
London,  1861)  has  observed  it  in  only  one-fourth  of  his  cases.  In  the 
majority  of  my  patients  the  pallor  hardly  lasted  a  few  seconds;  under  these 
conditions  it  may  readily  pass  unnoticed.  Not  infrequently  patients  suf- 
fering from  chronic  epilepsy  habitually  possess  a  pale  color,  and  this  pallor 
may  become  very  much  increased  without  being  noticed. 

Epilepsy,  the  most  marked  form  of  which  (haut  or  grand  mal)  we  have 
described  above,  embraces  certain  varieties,  which  are  distinguished  by 
the  intensity,  duration,  and  number  of  the  paroxysms.  In  a  somewhat 
lighter  form,  there  is  more  or  less  complete  loss  of  consciousness,  but 
without  the  utterance  of  a  cry  or  foaming  at  the  mouth;  there  is  no  spasm 
of  the  laryngeal  muscles,  and  cyanosis,  strong  pulsation  of  the  carotids, 
and  the  projection  of  the  eyeballs  are  wanting.  The  lightest  form  of 
the  disease  is  that  known  as  epileptic  vertigo  or  petit  mal.  In  this  form 
the  patients  suddenly  stop  in  their  work  or  occupation,  remain  immovable 
for  a  few  seconds,  and  then  return  to  their  previous  occupation.  At  other 
times  the  patients  are  suddenly  seized  with  vertigo,  are  forced  to  sit 
down,  lose  consciousness  for  a  very  short  period  or  even  inbompletely,  and 
merely  present  fugitive  contractions  of  the  eyelids,  the  arms,  or  hands.  At 
the  termination  of  such  attacks,  the  patient  comes  to,  looks  around  with 
astonishment,  and  all  the  symptoms  have  disappeared  within  five  to  eight 
minutes. 

The  existence  of  an  epileptogenic  zone  in  man  has  not  been  hitherto 
observed  except  in  a  few  cases  of  traumatic  epilepsy.  In  Schnee's  case, 
a  wound  in  the  head,  which  had  given  rise  to  epilepsy,  had  left  a  very 
painful  cicatrix,  by  touching  which  a  convulsion  could  be  produced. 
The  cicatrix,  in  which  evidences  of  neuritis  were  found,  was  excised,  and 
the  epilepsy  then  disappeared.  In  a  very  recent  case,  reported  by  Neftel 
(Arch.  f.  Psych.,  VII.  Bd.,  1877),  the  epilepsy  developed  in  a  young  man, 
after  a  blow  upon  the  head.  A  hyperaesthetic  epileptogenic  zone  was 
found  above  the  right  eye,  with  anaesthesia  of  the  corresponding  part  of 
the  healthy  side,  and  paralysis  of  the  frontal  nerve.  Internal  treatment 
was  at  first  employed  without  success,  and  recourse  was  then  had  to 
electricity  (the  negative  pole  to  the  neck,  the  positive  pole  with  the  stabile 
current  in  the  auriculo-mastoid  fossa),  which  furthered  the  disappearance 
of  the  spontaneous  pains  and  of  the  other  symptoms  of  the  disease. 

The  use  of  the  ophthalmoscope  in  epilepsy  has  produced  peculiarly 
interesting  results,  and  enables  us  to  judge  of  the  condition  of  the  cerebral 
circulation  from  that  of  the  retina. 

Koestl  and  Niemetschek  have  observed  (Prag.  Vjschr.,  Bd.  I.  and  III., 
1870)  retinal  anaemia  with  pallor  of  the  papilla  and  pulsation  of  the 
central  veins,  especially  upon  the  left  side  (on  account  of  the  incomplete 
filling  of  the  internal  carotid,  with  increase  of  pressure  in  the  venous  sys- 
tem). Tebaldi  (Riv.  Clin.,  IX.,  1870)  has  also  recognized  pallor  of  the 
papilla,  increase  in  the  venous  circulation,  and  (upon  examining  the  eye 
immediately  after  the  attack)  marked  congestion  of  the  veins,  with  rel- 
ative emptiness  of  the  arteries  —  phenomena  which  are  secondary  to 
arterial  anaemia  and  venous  hyperaemia  occurring  in  the  cerebral  vessels 
during  an  attack  of  epilepsy. 


68  CLINICAL    TPwEATISE    ON" 

In  the  very  large  majority  of  cases,  epileptics  present  more  or  less 
marked  psychical  disorders.  Previous  to  the  attack,  as  we  have  stated 
above,  intellectual  malaise  and  prostration  and  sensorial  illusions  of 
various  kinds  may  be  present;  mental  excitement  is  observed  at  times. 
During"  the  paroxysm  we  sometimes  notice  delirium,  but  only  in  attacks 
of  petit  mal.  After  the  seizure,  various  grades  of  the  so-called  "  folie 
epileptique  "  (Falvet)  are  noticeable.  In  the  slight  forms  the  patients 
have  attacks  of  melancholia,  they  are  morose,  dispirited,  associate  ideas 
with  difficulty,  wander  around  without  any  definite  aim,  and  manifest  a 
tendency  to  self-destruction  or  even  to  robbery,  incendiarism,  and  murder; 
after  they  have  recovered  their  calmness  and  consciousness,  they  re- 
member nothing  of  past  events.  In  the  more  severe  forms  they  suffer 
from  great  excitement  with  mania,  from  frightful  visions,  hallucinations, 
and  complete  delirium.  In  the  same  patients  we  may  observe  inter- 
mediate degrees  or  alternations  between  the  two  extreme  forms.  Epi- 
leptic insanity  may  last  from  several  hours  to  two  days. 

In  chronic  forms  the  psychical  disorders  may  become  permanent.  According'  to 
Esquirol  (Des  Maladies  mentales,  I,  p.  274,  Paris,  1838),  among  three  hundred  and 
eighty-five  epileptic  women,  forty-six  suffered  from  hysteria,  one  hundred  and 
forty-five  from  imbecility,  fifty  from  exaltation  or  weakness  of  memorj',  forty-eight 
from  mania,  and  eight  from  idiocy.  Hoffman  found  seventeen  cases  of  imbecility, 
twelve  of  mania,  two  of  furious  delirium,  and  two  with  entirely  normal  intellects, 
among  thirty-three  epileptic  patients.  According  to  Schroeder  van  der  Kolk,  the  light 
forms  of  epilepsy  often  give  rise  to  more  profound  psychical  disorders  than  the  severe 
convulsive  varieties. 

Epileptic  attacks  usually  occur  without  regularity;  it  is  only  rarely, 
and  for  a  short  time,  that  they  follow  a  determinate  type,  The  attacks 
present  a  much  greater  frequency  in  children  and  young  subjects  than 
at  a  more  advanced  age.  The  convulsions  are  almost  always  isolated, 
but,  in  rare  cases,  they  occur  in  groups  composed  of  paroxysms  occur- 
ring in  rapid  succession,  continuing  several  hours  or  even  days,  and  en- 
dangering the  life  of  the  patient. 

Another  severe  form  of  epilepsy  has  been  carefully  investigated  and 
described  by  Calmeil,  Trousseau,  Delasiauve,  Charcot,  and,  more  recently, 
by  Bourneville,  under  the  name  of  status  epilepticus.  It  presents  the 
following  characteristics:  rapid  succession  of  attacks,  presenting  very 
slight  remissions  and  without  return  of  consciousness  (convulsive  stage) ; 
a  comatose  condition  secondary  to  these  attacks,  with  abolition  of  reflex 
power,  except  during  short  periods  of  temporary  increase  (meningeal 
stage);  more  or  less  complete  and  permanent  hemiplegia;  acceleration  of 
the  pulse  and  respiration;  and,  especially,  a  marked  elevation  of  tempera- 
ture (40  °— i3  °  C),  which  even  persists  in  the  intervals  of  the  paroxysms, 
and  may  increase  after  their  disappearance  (Bourneville).  The  duration 
of  these  severe  attacks  may  vary  from  three  to  nine  days;  more  than  one- 
half  the  cases  terminate  in  death.  In  some  observations,  made  at  the 
Salpetriere,  unilateral  cerebral  atrophy  and  a  htemorrhagic  extravasation 
into  the  pia  mater  were  found  upon  autopsy,  thus  explaining  the  paraly- 
sis present  upon  the  opposite  side  of  the  body. 

Etiology. 

Epilepsy  is  attributable  either  to  an  individual  predisposition  or  to 
certain    exciting    causes:     Ileredity    is    one    of    the    chief    predisposing 


DISEASES    OF   THE   NERVOUS    SYSTEM.  69 

agencies.  This  factor,  in  the  strictest  sense,  refers  merely  to  epilepsy 
properly  speaking  (Esquirol  found  one  hundred  and  five  cases  of  heredity 
among  three  hundred  and  twenty-one  epileptics),  or,  in  a  larger  sense,  to 
the  tendency  to  nervous  diseases  which  exists  in  certain  families.  From 
the  latter  point  of  view,  Herpin  (Du  Pronostie  et  du  Traitement  curatif 
de  I'Epilepsie,  Paris,  1852),  in  examining  the  condition  of  the  parents  of 
two  hundred  and  forty-three  epileptics,  found  heredity  as  regards  nerv- 
ous diseases  in  almost  one-fourth  the  cases  (epilepsy,  seven  times,  insan- 
ity, eighteen;  apoplexy  and  hemiplegia,  eleven;  meningitis  and  hydro- 
cephalus, seven).  Nevertheless,  Petit  (Gaz.  de  Paris,  18,  1860)  cites 
examples  of  married  couples  with  healthy  children  and  grand-children, 
although  the  parents  were  epileptics  at  the  time  that  their  offspring  were 
born. 

Epilepsy  may  occur  at  all  ages.  The  most  marked  predisposition  is 
found  in  childhood  and  up  to  the  age  of  thirty  years;  the  largest  number 
of  cases  between  the  ages  of  twenty  and  thirty  years.  Epilepsy  may 
exist  in  children  from  birth;  in  cases  of  congenital  syphilis  it  may  ap- 
pear in  the  course  of  the  first  ten  years,  or,  at  a  later  period,  in  children 
who  have  suffered  from  eclampsia  during  early  childhood.  (I  am  ac- 
quainted with  a  family  in  which  two  children,  born  of  a  nervous  mother, 
died  of  eclampsia;  the  third  recovered  from  eclampsia,  and  remained  well 
until  the  age  of  twelve  years,  when,  during  the  first  menstrual  period,  and 
without  any  known  cause,  she  had  an  epileptic  attack  (petit  mal) ;  she 
has  been  subject  to  severe  and  light  attacks  for  the  last  fifteen  years.) 
The  female  sex  is  more  exposed  to  epilepsy  than  the  male,  on  account  of 
the  greater  impressionability  of  women  and  the  clearly  demonstrated  in- 
fluence of  menstruation.  We  also  know  that  certain  disorders  of  nutri- 
tion produce  an  abnormal  irritability  of  the  nervous  system,  and  give  rise 
to  epilepsy  under  the  influence  of  very  slight  exciting  causes.  These 
nutritive  disorders  include  anaemia,  chlorosis,  scrofula,  and  rickets.  But 
in  certain  cases  the  blood  is  only  affected  secondarily  after  the  epilepsy 
has  persisted  for  a  long  time.  According  to  Westphal,  chronic  alcohol- 
ism is  a  cause  of  epilepsy  in  drunkards;  one-third  of  the  patients  suffering 
from  delirium  tremens  were  previously  affected  with  epilepsy.  Observa- 
tions of  this  kind,  collected  by  Magnan,  only  refer  to  individuals  who 
have  indulged  to  excess  in  absinthe. 

Among  the  exciting  causes,  the  most  important  are  psychical  impres- 
sions, either  those  which  are  manifested  suddenly,  as  fright,  anger,  sur- 
prise, or  those  which  slowly  undermine  the  resistance  of  the  nervous 
system,  as  anxiety,  care,  misery,  and  privation.  The  diseases  of  the  brain 
and  its  membranes,  which  may  give  rise  to  epilepsy,  consist  of  cranial 
exostoses,  hypertrophy  of  certain  apophyses,  neoplasms  of  the  dura 
mater,  and  cerebral  tumors.  Among  the  latter,  the  tumors  of  the  con- 
vexity, of  the  anterior,  middle,  and  posterior  lobes,  and  of  the  motor 
ganglia,  are  most  frequently  accompanied  by  epileptic  seizures.  Epilep- 
tiform symptoms  are  also  observed  in  hydrocephalus,  cerebral  hyper- 
trophy, cerebral  syphilis,  parasites  of  the  brain  (cysticerci),  and  in  insanity. 
We  possess  some  observations  with  regard  to  the  spinal  origin  of  epilepsy 
in  man,  to  which  we  have  previously  referred  in  the  chapter  on  vertebral 
caries  and  other  lesions  of  the  vertebrae.  Some  cases  of  epilepsy  due  to 
a  lesion  of  the  sciatic  nerve  have  been  published  by  Billroth  (Langen. 
Arch.,  Bd.  XITI.,  1871 — disappearance  of  the  attacks  after  exposure  of 
the  adherent  sciatic  nerve)  and  Schaffer  (Aerztl.  Intelligenzbl.,  1871). 
Examples  of  epilepsy  caused  by   a   wound  in  the  head   are  mentioned 


70  CLINICAL    TREATISE    ON 

by  Kelp,  Leyden,  Meschede,  and  others,  but  a  feeling  of  terror  was  often 
produced,  simultaneously  with  the  wound,  and  it  is  very  difficult  to 
determine  the  part  played  by  each  of  these  factors. 

Irritation  proceeding  from  the  genital  organs  may  give  rise  to  epi- 
lepsy by  its  reaction  upon  the  nerve-centres.  We  have  discussed  this 
question  at  sufficient  length  in  the  chapter  on  hysteria  and  hystero-epi- 
lepsy  (uterine  epilepsy  of  the  ancients).  In  a  case  reported  by  C.  Maj'^er, 
the  epileptic  convulsions  ceased  after  the  restoration  of  a  uterine  ante- 
version.  In  young  subjects,  onanism  frequently  develops  epilepsy  and 
causes  its  continuance.  I  have  seen  two  cases  in  which  the  disease 
developed  after  the  first  acts  of  sexual  intercourse,  but  there  was  an  un- 
doubted hereditary  influence  acting  upon  these  patients. 

The  reflex  orig-in  of  epilepsy  is  as  rare  as  it  is  interesting.  I  have  had  the  oppor- 
tunity of  observing  one  example  of  this  character.  A  young  woman,  twenty-four 
years  of  age,  who  had  been  previously  healthj',  suffered,  at  the  end  of  the  fourth 
month  of  marriage,  after  the  performance  of  the  sexual  act,  from  acute  pains  in  the 
abdomen,  which  were  soon  attended  by  convulsions  combined  with  loss  of  conscious- 
ness. During  the  following  weeks  the  patient  abstained  from  coitus,  and  enjoyed 
perfect  health.  When  she  again  indulged  in  sexual  intercourse,  the  epileptic  seizures 
returned  and  soon  began  to  occur  spontaneously,  at  first  only  at  the  menstrual  epochs, 
and,  at  a  later  period,  irrespective  of  the  menses.  The  patient  did  not  place  herself 
under  medical  care  until  after  separation  from  her  husband.  Upon  examination,  a 
very  sensitive  point  was  found  at  the  anterior  and  inferior  portion  of  the  vestibule  of 
the  vagina,  at  the  level  of  the  remains  of  the  hymen  and  of  the  adjacent  mucous 
membrane.  An  attack  of  epilepsy  could  be  invariably  produced  by  pressing  upon 
this  point,  and  even  by  touching  it  lightly  with  nitrate  of  silver ;  if  the  examination 
were  prolonged,  the  attack  lasted  much  longer.  The  uterus  was  nomaal  and  insensi- 
ble to  pressure ;  there  were  no  sj'mptoms  of  hysteria.  Ferruginous  mineral  waters 
and  local  treatment  proved  ineffectual,  but  the  attacks  of  epilepsy  disappeared  after 
the  excision  of  the  sensitive  parts,  and  have  remained  absent  for  the  past  two  years. 

Finally,  ^)er?/:)/*e7*ff^  irritation  (cicatricial  retractions,  foreign  bodies, 
worms,  neuromata)  may  implicate  the  brain,  by  direct  irradiation  or  by 
reflex  means,  and  may  give  rise  to  symptoms  of  epilepsy.  Levinstein 
has  published  (Deutsche  Klinik,  Oct.,  18G7)  two  cases  in  which  the  pa- 
tients, after  having  borne  heavy  burdens,  became  affected  with  convulsive 
movements  in  the  arms;  shortly  afterwards  these  movements  also  affected 
the  face,  and  terminated  in  loss  of  consciousness.  The  discovery  of  these 
etiological  factors  determined  the  nature  of  the  treatment  to  be  employed 
in  these  cases.  (Recovery  was  obtained  by  the  employment  of  the  con- 
tinuous current.) 

The  Nature  of  Ejulejisy, 

For  a  few  years  past,  experimenters  have  been  busily  investigating 
the  pathogeny  of  epileptic  affections.  Although  they  have  been  unable 
to  discover  the  intimate  changes  which  lie  at  their  foundation,  experi- 
mentation has,  nevertheless,  revealed  to  us  various  factors  which  are 
capable  of  giving  rise  to  epileptic  seizures.  We  shall  attempt,  in  the 
following  remarks,  to  throw  into  relief  the  essential  features  of  the  pres- 
ent theories  on  this  question.  Solly's  theory  of  arterial  congestion  ap- 
pears insufficient  to  explain  the  phenomena  of  epilepsy.  This  hypothesis 
is  contradicted  by  the  appearance  of  convulsions  in  animals  who  have 
been  deprived  of  blood,  and  by  the  experiments  of  Kussmaul  and  Tenner. 
By  artificially  producing  intense  cerebral  hyperaemia  (by  section  of  the 
cervical  sympathetic,  and   ligature  of  the  internal  and  external  jugular 


I 


DISEASES    OF    THE    NEKVOUS    SYSTEM.  71 

veins),  these  authors  noticed  the  development  of  dizziness,  weakness  of  the 
legs,  exophthalmia,  and  slowness  of  the  respiration,  but  no  epileptiform 
convulsions.  It  must  also  be  remembered  that  in  epilepsy  the  loss  of 
consciousness  occurs  at  a  period  when  the  face  is  pale,  and  that  in  those 
cases  in  which  there  is  a  considerable  flow  of  blood  to  the  brain  (as  in 
hypertrophy  of  the  left  ventricle),  vertigo,  apoplexy,  and  paralysis  occur, 
while  epilepsy  never  does  (Romberg).  The  appearance  of  epileptiform 
attacks  under  the  influence  of  venous  stases  has  been  rendered  doubtful 
by  Kussmaul;  nevertheless  the  experiments  of  Landois  and  Herrmann, 
which  we  have  quoted  above,  have  directly  demonstrated  their  occur- 
rence. 

According  to  Schroeder  van  der  Kolk,  the  pathogenic  condition  in 
epilepsy  is  an  exaggerated  excitability  of  the  medulla  oblongata,  which 
is  always  associated  with  dilatation  of  the  vessels  in  this  organ  and  in 
the  neighboring  parts.  This  dilatation,  which  increases  with  the  con- 
tinuance of  the  paroxysms,  gives  rise,  on  the  one  hand,  to  reflex  move- 
ments from  congestive  irritation  of  the  ganglion-cells,  and,  on  the  other 
hand,  to  exudations,  thickening,  and,  finally,  to  fatty  degeneration  of  the 
vascular  walls.  The  dilatation  of  the  vessels  also  extends  to  the  cerebral 
cortex,  causing  psychical  disorders  attended  by  excitement  from  irritation 
of  the  ganglion-cells,  and,  later,  produces  imbecility  and  idiocy  from  de- 
struction of  these  cells.  The  disorders  of  speech,  which  are  sometimes 
observed  in  epilepsy,  may  be  explained  by  changes  in  the  olivary  bodies 
and  in  the  nuclei  of  the  hypoglossal  and  facial  nerves.  While  admit- 
ting that  Schroeder's  deductions  are  not  invulnerable  at  all  points,  they 
nevertheless  possess  the  merit  of  calling  attention  to  the  part  played  by 
the  medulla  oblongata  in  epilepsy,  a  view  which  is  still  further  confirmed 
by  later  experiments. 

Marshall  Hall  has  atbcibnted  the  principal  part  in  the  production  of  epilepsy  to  tlie 
tonic  spasm  of  the  muscles  of  the  neck  (trachelismus)  and  of  the  muscles  of  the  larynx. 
Some  of  the  symptoms  (loss  of  consciousness)  are  due  to  obstruction  to  the  return 
circulation,  and  others  (clonic  spasms)  to  the  asphyxia.  This  theory  is  refuted  by  the 
fact  that  the  paroxysm  does  not  always  begin,  as  Marshall  Hall  supposed,  with  spasm 
of  the  glottis,  but,  in  the  large  majority  of  cases,  with  loss  of  consciousness  ;  at  other 
times  the  clonic  convulsions  are  well  marked,  before  laryngismus  has  developed.  But 
to  M.  Hall  belongs  the  credit  of  having  first  pointed  out  the  analogies  between  spasm 
of  the  glottis  and  strangulation,  and  epilepsy. 

Finally,  the  previously  mentioned  experiments  of  Kussmaul  and  Ten- 
ner demonstrated  that  the  loss  of  consciousness  and  the  convulsive  move- 
ments are  due  to  a  sudden  and  considerable  cerebral  anaemia,  caused  by  a 
spasm  of  the  cerebral  arteries.  According  to  these  researches,  the  point 
of  departure  of  the  vascular  spasm  is  found  in  the  medulla  oblongata;  in 
the  attacks  of  epilepsy,  caused  by  spasm  of  the  glottis,  it  is  found  in  the 
nuclei  of  origin  of  the  pneumogastric  and  spinal  accessory  nerves. 

The  loss  of  consciousness  and  the  insensibility  have  their  origin  in  the 
cerebral  hemispheres,  the  convulsions  in  the  excitable  region  situated  be- 
hind the  optic  thalami. 

We  will  now  examine  with  greater  attention  the  characteristic  symp- 
toms which  are  manifested  on  the  part  of  the  vascular  system.  As  the 
majority  of  authors  admit,  almost  all  epileptics  become  pale  a  short  time 
previous  to,  and  at  the  beginning  of,  the  attack. 

In  some  cases  reported  by  Rosenstein  (Berl.  Klin.  Wschr.,  21,  18G8), 
the  sensory  disorders  constituting  the  aura  were  situated  in  nerves,  whose 


72  CLimCAL   TKEATISE    ON 

relations  with  the  vascular  nerves  of  the  brain  are  well  known  (pains 
radiating  into  one  of  the  supraorbital  nerves,  into  the  occiput,  cheeks, 
and  nose,  redness  of  one-half  of  the  nose,  swelling  of  the  eyelids,  followed 
by  pallor  of  the  face,  loss  of  consciousness,  and  convulsions) ;  in  other 
patients  the  aura  consisted  chiefly  of  disorders  on  the  part  of  the  vaso- 
motor nerves.  In  epileptic  guinea-pigs,  Brown-Sequard  has  seen  narrow- 
ing of  the  arteries  of  the  pia-mater  at  the  beginning  of  a  convulsion.  As 
Voisin  has  observed  in  epileptics  by  means  of  the  sphygmograph  (Ann. 
Med.  Psychol.,  July,  1867),  the  initial  contraction  and  subsequent  relaxa- 
tion of  the  arteries  are  recognized  by  the  following  signs:  the  line  of  as- 
cent of  the  pulse,  which  is  at  first  lower,  becomes  markedly  higher,  its 
convexity  becomes  more  pointed,  and  the  line  of  descent  is  markedly  di- 
crotic. The  pulse  gave  the  same  trace  in  patients  who  suffered  from  epi- 
leptic vertigo,  although  similar  phenomena  were  not  observed  in  healthy 
subjects.  The  occurrence  of  vascular  spasm  is  further  confirmed  by  an 
arterial  anomaly  observed  by  Pereira  in  an  individual  in  whom  the  carotid 
originated  from  the  vertebral  through  the  medium  of  the  basilar;  this 
patient  was  epileptic,  and  absence  of  the  radial  pulse  (from  spasm  of  the 
carotid  and  vertebral)  was  observed  during  the  epileptic  fits.  I  have  also 
published  (Vol.  I.,  p.  100)  a  case  of  cerebral  tumor  which  supports  this 
theory;  in  this  case  the  epileptiform  attacks  were  accompanied  by  sud- 
den pallor,  and  the  pulse  became  small  and  feeble.  Finally,  the  antemic 
origin  of  epilepsy  is  still  further  substantiated  by  observations  of  embo- 
lism of  the  carotid  (as  in  a  case  of  aneurism  of  the  aorta,  in  Oppol- 
zer's  Clinic),  accompanied,  during  life,  by  severe  eclamptic  attacks,  and, 
by  the  analogous  phenomena  which  occur  in  certain  puerperal  metrorrha- 
gias, and  after  certain  operations  of  ligature  of  the  carotid. 

In  fact,  the  hypothesis  of  a  vaso-motor  neurosis  of  the  brain  offers  the 
most  satisfactory  and  simple  solution  of  the  phenomena  which  occur  dur- 
ing an  attack  of  epilepsy.  A  vascular  spasm,  starting  from  the  vaso-mo- 
tor centre,  rapidly  becomes  general,  and  causes  cerebral  anaemia,  thus 
causing  an  obstruction  to  the  reciprocal  reactions  which  transj^ire  between 
the  blood  and  the  brain.  This  circulatory  disturbance  in  the  cerebral 
hemispheres  gives  rise  to  loss  of  consciousness,  and  acts,  on  the  other 
hand,  as  a  powerful  stimulus  of  the  centre  of  convulsive  movements  which 
is  situated  in  the  pons  varolii  and  medulla  oblongata.  The  nuclei  and 
the  root  fibres  of  the  sensory  cranial  nerves,  which  occupy  this  region, 
and  the  fibres  of  the  tegmentum,  which  are  interspersed  with  ganglion- 
cells,  readily  transmit  the  stimulus  to  the  motor  fibres. 

The  cerebral  anasmia  also  acts  as  a  strong  irritant  to  the  respiratory 
centre  bordering  upon  the  regions  which  we  have  mentioned.  The  irri- 
tation is  gradually  propagated  to  the  centres  of  innervation  of  the  various 
respiratory  muscles,  and  produces  severe  dyspnoea  and  spasm  of  the  re- 
spiratory muscles,  thus  tending  to  increase  the  venous  repletion  of  the 
brain.  The  irritation  of  the  trigeminus  in  epilepsy,  which  Brown-Sequard 
has  observed  in  his  experiments,  is  explained  by  the  part  which  the  large 
root  of  this  nerve  takes  in  the  formation  of  the  tegmentum  pedunculi. 

When  this  abnormal  excitability  of  the  nerve-centres,  which  is  pecu- 
liar to  epileptics,  is  present,  it  is  very  probable  that  the.  irritation  of  the 
cerebral  and  spinal  centres,  which  we  have  mentioned,  is  produced  simul- 
taneously. This  appears  to  be  especially  so  in  severe  and  old  forms.  In 
the  milder  forms,  in  which  either  the  loss  of  consciousness  or  the  convul- 
sions predominate  at  first,  it  appears  that  the  stimulation  of  one  of  these 
centres  prevails  over  that  of  the  other.     This  depends  probably  upon  the 


DISEASES    OF   THE    NERVOUS    SYSTEM.  73 

primary  degree  of  intensity  and  extension  of  the  vaso-motor  irritation.  A 
rapidly  subsiding  vaso-motor  irritation,  with  unequal  distribution  of  the 
blood  in  the  cerebral  lobes,  will  give  rise  to  epileptic  vertigo,  or  petit  mal. 
A  circumscribed  vascular  spasm  produces  partial  epilepsy;  severe  attacks 
depend  upon  a  central  vascular  spasm,  recurring  periodically  and  devel- 
oping rapidly;  the  status  epilepticus  is  produced  by  a  continuous  central 
irritation,  preventing,  in  the  beginning,  the  return  of  consciousness,  and 
then  terminating  in  inflammatory  exudations,  and  perhaps  even  in  paral- 
ysis of  the  vaso-motor  centres. 


Diagnosis. 

As  a  rule,  no  difficulty  is  experienced  in  recognizing  an  attack  of  true 
epileps}';  but  certain  forms  may  lead  to  error,  especially  those  which  are 
characterized  by  incomplete  paroxysms.  The  comatose  condition  follow- 
ing an  attack  may  be  mistaken  for  apoplectic  coma  (Sauvages,  Trousseau), 
especially  when  the  onset  of  the  attack  has  not  been  seen,  or  when  the 
slight  spasms  have  been  overlooked.  When  the  coma  is  prolonged  (this 
occurs  in  certain  cases,  especially  in  old  age),  the  diagnosis  is  rendered 
certain  after  it  becomes  evident  that  no  paralysis  exists  during  and  im- 
mediately after  the  coma. 

The  signs  which  distinguish  an  epileptic  fit  from  an  hysterical  paroxysm 
have  been  referred  to  under  the  head  of  Diagnosis  of  Hysteria.  In 
eclampsia  all  the  characteristic  signs  are  similar  to  those  occurring  in 
epilepsy.  In  order  to  exclude  epilepsy,  we  should  pay  attention  to  the 
existence  of  pregnancy  or  the  puerperal  condition,  to  disorders  of  the 
urinary  secretion,  to  the  presence  of  an  abundance  of  albumen  and  of 
casts  in  the  urine,  to  the  existence  of  dropsy  and  the  discovery  of  car- 
bonate of  ammonia  in  the  blood  drawn  by  venesection.  It  is  much  more 
difficult  to  discover  positive  signs  which  will  enable  us  to  differentiate  the 
eclampsia  of  children  from  epilepsy.  On  account  of  the  delicate  organi- 
zation and  peculiar  excitability  of  the  brain  of  the  child,  an  increased  flow 
of  blood  to  the  head,  the  exhaustion  following  diarrhoea,  or  an  irritation 
originating  in  the  digestive  canal,  may  give  rise  to  epileptiform  convul- 
sions. In  order  to  make  a  correct  diagnosis,  the  physician  must  take  into 
consideration  all  the  surrounding  circumstances,  and  all  symptoms  which 
may  indicate  an  affection  of  the  cranial  meninges  or  of  the  brain  ;  the 
development  of  tuberculous  cerebral  tumors,  which  are  accompanied  by 
disorders  of  motion,  sensation,  and  the  special  senses,  must  also  be  con- 
sidered. 

Many  authors  have  complicated  the  discussion  of  epilepsy  in  adults 
by  establishing  artificial  categories  which  are  hardly  justifiable.  This 
classification,  moreover,  possesses  no  interest,  either  from  a  theoretical  or 
a  practical  point  of  view.  The  simplest  and,  at  the  same  time,  the  best 
plan  is  that  of  determining  in  each  case  whether  the  disease  is  central  or 
peripheral,  idiopathic  or  symptomatic. 

Idiopathic  central  epilepsy  is  recognized  without  difficulty,  in  the 
majority  of  cases,  by  devoting  some  attention  to  the  etiological  factors. 
Tlie  symptomatic  forms  of  central  epilepsy  are  distinguished  by  the 
previous  history  and  by  other  characteristic  signs  belonging  to  the  pri- 
mary disease.  The  epileptiform  attacks  which  occur  as  intercurrent 
phenomena  in  cerebral  tumors  (tumors  of  the  convexity,  anterior  and 
posterior  lobes,  motor  ganglia,  and  cerebellum)  are  almost  always  suffi- 


74  CLINICAL    TREATISE    OIT 

ciently  explained  by  the  coexisting  motor  and  sensory  disorders.  We 
have  previously  mentioned  (Vol.  I.,  p,  139)  the  probable  signs  of  epilepsy 
caused  by  cysticerci  of  the  brain.  The  epileptiform  symptoms  of  cere- 
bral syphilis  and  of  congenital  cerebral  sj-philis  have  also  been  discussed 
(Vol.  I.,  p.  152).  Epileptiform  seizures  which  are  caused  by  cerebral  hy- 
pertrophy and  embolism  of  the  internal  carotid  (three  times  in  thirty-nine 
cases,  according  to  Lancereaux)  are  accompanied  by  other  grave  symp- 
toms, to  which  we  have  previously  referred.  In  paralytic  dementia,  epi- 
leptiform attacks  occur  in  the  beginning,  or,  more  frequently,  at  a  more 
advanced  period;  but  the  parts  affected  by  the  convulsions  almost  always 
remain  paralyzed  for  a  certain  length  of  time,  and  contractures  are  ob- 
served during  and  after  the  attack  ;  not  infrequently  some  embarrassment 
of  speech,  or  other  characteristic  phenomena  of  paresis  or  paralysis  in  the 
muscular  system,  is  noticeable  after  the  epileptic  seizure. 

In  pcrijjheral  epilejysr/ the  disorders  of  motion  or  sensation  precede  the 
loss  of  consciousness;  the  secondary  participation  of  the  brain,  leading  to 
the  attack,  occurs  from  irradiation  or  reflex  action.  In  order  to  diagnos- 
ticate this  variety  of  epilepsy,  we  must  be  able  to  find,  by  examining  or 
questioning  the  patient,  a  peripheral  irritation  or  a  nervous  lesion,  which 
will  account  for  the  starting-point  of  the  disease.  Epilepsy,  which  is  thus 
produced  by  irritation  from  worms,  cicatrices,  or  traumatism  (Levinstein), 
is  readily  susceptible  of  recovery.  The  simulation  of  epilepsy  is  fre- 
quently attempted,  and  is  sometimes  difficult  to  detect;  but  careful  obser- 
vation will  usually  enable  us  to  recognize  the  deceit.  The  satisfaction 
with  which  the  individuals  refer  to  their  disease,  and  the  time  and  place 
which  they  choose  for  the  attacks  in  order  to  accomplish  their  end,  con- 
trast markedly  with  the  disposition  of  true  epileptics,  who  confess  to  the 
existence  of  their  complaint  with  timidity  and  sorrow.  The  exaggeration 
of  the  symptoms  of  the  fit,  the  imperfect  copy  of  the  asphyxia,  the 
fatigue  which  rapidly  develops,  the  signs  of  irritability  produced  by  the 
sudden  application  of  strong  electrical  currents,  the  action  of  light  upon 
the  pupils  (according  to  Romberg  they  do  not  react  in  true  epilepsy)  are 
other  features  which  enable  us  to  unmask  the  imposition.  Voisin  has 
recently  employed  for  the  same  purpose  the  examination  of  the  pulse 
with  the  sphygmograph ;  we  have  seen  that  this  instrument  gives  a  pecu- 
liar trace  in  epileptics,  on  account  of  the  existence  of  vascular  spasm. 


J*rognos?.s. 

Hippocrates,  Galen,  Morgagni,  Boerhaave,  Tissot,  and  Odhelius  admit 
the  curability  of  epilepsy;  Esquirol,  Georget,  Valleix,  Monneret,  Delasi- 
auve.  Beau,  etc.,  took  a  pessimistic  view  of  the  question,  and  abandoned 
the  patients  to  their  unhappy  fate,  without  any  attempt  at  treatment. 
In  later  times.  Trousseau,  Herpin,  and  Portal  have  endeavored  to  free 
epilepsy  from  this  long  proscription,  and  Trousseau  has  stated  (Gaz.  des 
Ilopit.,  April.  1855)  that  in  twelve  years  he  obtained  twenty  recoveries 
among  one  hundred  and  fifty  cases  of  epilepsy.  We  can  readily  under- 
stand why  a  recovery  from  this  disease  should  be  much  more  strongly 
doubted  by  hospital  phj^sicians  than  by  those  in  private  practice,  the  for- 
mer coming  in  contact  with  chronic  forms,  complicated  with  mental 
diseases,  and  the  latter  seeing  cases  in  the  early  stages.  Spontaneous 
recoveries  are  exceedingly  rare  (about  four  per  cent.,  according  to  Beau 
and  Maisonneuve).     The  elements  of  the  prognosis  are:  the  etiological 


DISEASES    OF   THE    NERVOUS    SYSTEM.  75 

conditions  of  the  disease,  the  age  at  which  it  develops,  its  duration,  and 
the  frequency  of  the  attacks.  The  idiopathic  variety  presents  a  favorable 
prognosis  when  it  is  treated  early  and  is  not  complicated  by  any  hereditary 
influence.  We  must  not  neglect  to  treat  petit  mal,  and  must  take  into 
consideration  all  the  individual  circumstances  of  the  case.  Symptomatic 
epilepsy  has  slight  chances  of  recovery.  The  most  severe  form  is  that  due 
to  the  presence  of  cerebral  tumors;  there  is  much  more  chance  of  recovery 
when  the  disease  is  secondary  to  cerebral  syphilis  or  lead-poisoning. 
Those  forms  which  are  complicated  with  insanity  present  few  chances  of 
recovery.  Schroeder  van  der  Kolk  has,  nevertheless,  seen  patients,  who 
had  become  insane  from  the  influence  of  epilepsy,  recover  from  the  men- 
tal disorder  after  a  cure  of  the  epilepsy  had  been  effected.  The  prog- 
nosis is  more  favorable  in  reflex  epilepsy;  if  we  can  succeed  in  removing 
the  causes  of  irritation,  which  are  acting  from  the  periphery,  the  epilepsy 
will  disappear  at  the  same  time.  It  is  stated  that  the  disease  is  curable 
when  it  develops  during  the  period  of  dentition  ;  it  is  regarded  as  incur- 
able when  it  begins  in  the  early  years  of  childhood  and  is  prolonged  be- 
yond the  age  of  puberty.  Cases  which  develop  during  youth,  especially 
those  which  are  due  to  disorders  of  the  genital  organs  (with  the  ex- 
ception of  those  caused  b}^  an  inveterate  habit  of  onanism),  have  a  more 
favorable  prognosis  than  those  appearing  in  adult  life.  Nocturnal  epi- 
lepsy is  more  dangerous  than  the  diurnal  form,  because  it  affects  the 
patient  during  sleep  and  often  when  he  is  not  under  surveillance.  The 
varieties  attributed  to  chlorosis,  ansemia,  or  other  unfavorable  conditions, 
may  recover  if  these  causes  are  removed  in  time.  The  duration  of  the 
disease  is  of  the  greatest  importance  with  regard  to  prognosis,  and  re- 
covery is  so  much  the  more  difficult  the  longer  the  disease  has  lasted. 
The  prognosis  improves  if,  during  the  course  of  the  disease,  the  fits  ap- 
pear more  infrequently  and  are  shorter  and  lighter.  When  the  patients 
have  long  remissions,  during  which  they  merely  present  epileptic  vertigo, 
we  may  always  hope  for  recovery,  according  to  Herpin,  if  the  disease  has 
not  lasted  more  than  ten  years.  The  prognosis  is  not  unfavorable  if  the 
number  of  attacks  does  not  exceed  one  hundred  ;  if  the  attacks  number 
from  one  hundred  to  five  hundred  the  situation  is  grave,  and  becomes 
still  more  serious  if  they  exceed  the  latter  figure. 

We  should  be  very  reserved  in  giving  a  prognosis,  and  very  skeptical 
with  regard  to  cases  of  recovery,  since  relapses  are  frequent,  and  may 
occur  even  after  the  attacks  have  disappeared  for  several  years.  The  fits 
may  become  more  infrequent  under  the  influence  of  strict  habits  of  life 
and  diet,  and  the  patients  may  enjoy  satisfactory  health  for  years,  but, 
as  a  rule,  they  do  not  live  to  an  advanced  age.  Death  may  occur  during 
a  convulsion  from  a  fall,  from  asphyxia,  pulmonary  oedema,  cerebral  hjem- 
orrhage,  or  rupture  of  the  heart  (Short  and  Voisin).  Irrespective  of  the 
convulsions,  death  is  caused  by  marasmus,  tuberculosis,  cerebral  softening, 
and  various  intercurrent  diseases. 


Treatment. 

At  the  onset  of  the  affection  the  chief  aim  consists  in  relieving  the 
morbid  impressionability  of  the  nerve-centres,  and  the  extreme  excita- 
bility of  reflex  action,  before  the  functional  disorders  have  become  estab- 
lished in  a  chronic  form  and  have  produced  tissue  changes  in  the  nerve- 
cells. 


76  CLINICAL    TREATISE    ON 

Recovery  is  impossible  unless  we  are  able  to  moderate,  by  a  suf- 
ficiently complete  and  prolonged  rest,  the  peculiar  erethism  of  the  nerve- 
centres.  Before  we  can  state  with  certainty  that  recoverj»^  from  epilepsy 
lias  occurred,  the  nervous  system  must  have  presented  no  derangement 
for  a  number  of  years,  and  its  integrity  must  have  been  proven  by  its  re- 
sistance to  numerous  and  varied  irritations.  If  this  is  done,  the  number 
of  so-called  recoveries  will   be  found  to  diminish  very  considerably. 

During  the  attack  we  should  endeavor  to  protect  the  patient  from  in- 
juring himself,  from  falling  out  of  bed,  and  from  biting  the  tongue  (by 
placing  a  cork,  or  a  small  piece  of  wood  covered  with  a  cloth,  between  the 
teeth),  and  should  remove  the  mucus  which  accumulates  in  the  mouth  and 
w^hich  may  give  rise  to  symptoms  of  asphyxia.  Parry  has  employed  com- 
pression of  the  carotids  or  the  inhalation  of  chloroform  in  order  to  shorten 
asphyxial  attacks  of  long  duration  ;  these  measures  are  only  indicated  in 
extremely  rare  cases. 

The  treatment  of  epilepsy  should  be  begun  by  endeavoring  to  remove 
the  cause  although  this  is  usually  more  easily  said  than  done.  It  is,  above 
all,  necessary  to  examine  the  various  internal  viscera  as  carefully  as  possi- 
ble. Retracting  cicatrices,  tumors,  osseous  sequestra,  foreign  bodies, 
worms,  and  concretions  sometimes  give  rise  to  attacks  of  epilepsy,  which 
do  not  disappear  until  the  offending  substance  is  removed.  In  Rosenstein's 
cases,  in  which  the  attacks  were  preceded  by  vaso-motor  irritation,  and  in 
Levinstein's  two  patients,  who,  after  having  carried  heavy  burdens,  suf- 
fered from  spasms  in  the  upper  limbs,  terminating  in  true  epileptic  con- 
vulsions, recovery  followed  tonic  treatment  and  the  application  of  the 
constant  current  to  the  diseased  nerves. 

In  young,  delicate  subjects,  especially  those  near  the  age  of  puberty, 
we  can  evidently  produce  the  most  favorable  conditions  for  recovery,  by 
methodically  increasing  the  vigor  of  the  nervous  system,  by  calming  its 
abnormal  excitability,  and  by  developing  its  power  of  resistance  against 
all  forms  of  irritation.  A  prolonged  trip  to  the  country,  the  removal  of 
everything  which  tends  to  stimulate  the  intellect  and  sexual  appetite, 
and  well-regulated  hydrotherapeutic  treatment  (frictions,  half-baths,  dor- 
sal affusions)  may  cause  the  attacks  to  disappear.  I  know  that  this  re- 
sult can  be  achieved  in  many  cases.  In  a  young  man  under  my  care 
attacks  of  epilepsy  which  were  due  to  onanism,  disappeared  after  mod- 
erate indulgence  in  sexual  intercourse. 

With  regard  to  medicinal  treatment,  we  shall  only  discuss  those  old 
remedies  which  are  still  in  use,  and  the  new  remedies  with  whose  action 
we  are  somewhat  better  acquainted. 

The  salts  of  zinc  (oxide,  valerianate,  and  lactate)  have  been  highly 
praised  by  Herpin,  who  obtained  good  results  therefrom  (in  more  than 
one-half  of  his  cases),  especially  in  children  and  old  people.  The  prep- 
arations of  zinc  should  be  administered  to  children,  in  increasing  doses, 
from  0.05-0.50  p.  d.,  and  continued  for  several  months.  In  adults  0.50-3. 
grammes  are  given  daily,  and  treatment  should  not  be  discontinued  unless 
fifty  to  one  hundred  grammes  of  the  remedy  have  been  taken  without  any 
good  effects.  Other  observers  are  much  more  guarded  in  their  praises 
of  this  drug. 

The  preparations  of  copper,  bismuth,  and  antimony  are  very  little  used 
at  the  present  time,  with  the  exception  of  the  ammoniated  sulphate  of 
copper,  which  is  sometimes  employed  (0.03-0.07  p.d.,  Herpin).  Nitrate 
of  silver  is  one  of  the  most  highly  recommended  of  the  metallic  prepara- 
tions.    It  is  prescribed  in  pill  form,  O.OOG-0.02  being  given  twice  a  day 


DISEASES    OF   THE    NERVOUS    SYSTEM.  77 

in  the  beginning',  and  tiie  dose  being  then  increased  until  0.20  is  ad- 
ministered in  the  twenty-four  hours.  1  have  never  seen  argyrism  pro- 
duced before  the  patient  had  taken  five  grammes  of  the  drug.  In  all  cases, 
it  is  well  to  suspend  treatment  temporarily  after  it  has  been  continued 
for  a  certain  length  of  time,  especially  if  the  patients  complain  of  pains 
in  the  stomach.  Cases  of  complete  recovery  under  this  plan  have  been  re- 
ported, but,  in  very  many  cases,  the  only  results  obtained  were  the  pro- 
duction of  symptoms  referable  to  the  argyrism.  Trousseau  has  seen  one 
patient  who  experienced  no  benefit  despite  the  existence  of  argyrism,  and 
despite  castration  and  tracheotomy,  which  were  performed  upon  the  pa- 
tient, at  a  later  period,  in  England. 

Fowler's  solution  is  given  in  doses  of  five  to  ten  drops  p.  d.  (upon  a 
lump  of  sugar),  and  has  a  favorable  effect  upon  the  form  of  the  disease. 
The  ferruginous  preparations,  especially  the  carbonate  and  cyanide  of  iron, 
often  produce  good  effects  in  ann?mic  patients.  Belladonna,  which  was 
first  employed  by  Greding,  has  been  extolled  more  recently  by  Michea 
and  Trousseau.  On  account  of  the  ready  decomposition  of  the  leaves 
and  of  tlie  extract  of  belladonna,  and  the  unequal  proportions  of  atro- 
pine which  they  contain,  even  in  the  fresh  condition,  it  is  better  to 
prescribe  atropine  in  the  form  of  the  sulphate  (according  to  Michea  in 
the  form  of  acid  valerianate).  According  to  Skoda  (Allg.  med.  Zeit., 
14,  1860),  atropine  is  relatively  the  best  remedy  against  epilepsy  in  our 
possession.  0.03-0.05  of  sulphate  of  atropia  are  dissolved  in  five  grains 
of  water,  and  one  to  two  drops  of  this  solution  are  given  daily.  The 
dose  is  increased  each  week  by  a  drop  daily;  the  patient  is  held  at  the 
dose  which  has  produced  manifest  improvement,  and  the  dose  is  then 
gradually  diminished  in  an  inverse  ratio.  From  time  to  time  it  is  neces- 
sary to  suspend  treatment,  especially  if  considerable  dilatation  of  the 
pupils  occurs,  with  marked  dryness  of  the  throat,  muscular  weakness,  and 
disorders  of  the  special  senses. 

Bromide  of  potassium  was  first  administered  in  epilepsy  by  Locock 
and  M'Donnel,  and  the  latter  author  called  attention  to  the  efficacy  of 
the  drug  in  large  doses.  For  some  time  past  the  remedy  is  also  used 
largely  in  France  and  England. 

According  to  the  experiments  made  by  Eulenburg  and  Guttmann, 
both  upon  cold-blooded  and  warm-blooded  animals  (Virch,  Arch.,  1.  H., 
1867),  bromide  of  potassium  acts  chiefly  upon  the  central  nervous  system, 
and  gradually  diminishes  motor  power,  as  well  as  sensory  perceptions  and 
reflex  excitability,  until  they  entirely  disappear.  In  order  to  obtain  re- 
sults in  man  which  are  at  all  comparable  to  the  effects  just  described, 
large  doses  must  be  administered.  We  begin  with  four  grammes  daily 
(which  the  patient  dissolves  in  a  glass  of  sugar-water,  or  encloses  in  a 
wafer),  and  increase  this  dose,  in  ordinary  cases,  until  six  to  nine  grammes 
are  taken  daily.  In  severe  forms  we  may  begin  with  the  latter  dose  and 
increase  it  up  to  twelve  grammes  (rarely  much  higher).  I  have  become 
convinced  that  this  drug  is  more  useful  in  recent  than  in  old  cases,  but, 
even  in  the  latter,  it  almost  always  diminishes  the  number  and  violence 
of  the  attacks.  Radcliffe,  Brown-Sequard,  Russell-Reynolds,  Voisin,  Le- 
grand  du  Saulle,  Pletzer,  and  Eulenburg  have  reported  cases  of  perma- 
nent recovery  from  the  employment  of  bromide  of  potassium.  In  epi- 
leptic hysteria,  in  which  the  attacks  occur  with  the  menses,  benefit  is 
derived  from  the  use  of  the  drug  for  a  short  time  before  each  menstrual 
period. 

According  to  the  observations  of  Guttmann  and  Sander,  the  effect  upon 


78  CLINICAL   TREATISE    ON 

the  nervous  system  is  due  to  the  alkaline  base,  but  the  same  results  have 
not  been  obtained  from  chloride  of  potassium.  The  use  of  bromide  of  po- 
tassium may  be  attended  with  some  annoying  symptoms,  such  as  the  appear- 
ance of  acne  pustules,  and,  much  more  rarely,  of  angina  or  gastric  disturb- 
ances, which  disappear  after  a  short  suspension  of  the  treatment.  This 
remedy  may  be  given  for  several  months  in  succession,  with  short  intermis- 
sions, and  the  gravity  of  the  disease  demands  that  this  method  of  treat- 
ment should  receive  the  necessary  care  and  attention.  In  sensitive  patients 
we  may  employ  the  bromide  of  sodium,  which,  in  my  experience,  acts  as 
a  milder  remedy  than  the  corresponding  salt  of  potassium.  Curare  was 
first  recommended  in  epilepsy  by  Thiercelin  (Acad,  des  Sciences,  Nov., 
1860),  and  then  by  Benedikt.  In  a  certain  number  of  cases,  I  have  em- 
ployed a  solution  of  0.05  of  curare  in  five  grammes  of  w-ater,  with  the 
addition  of  three  or  four  drops  of  absolute  alcohol.  For  a  period  of  two 
or  three  months  I  gave  a  subcutaneous  injection  every  two  days,  increas- 
ing the  dose  gradually  from  0.004-0.009.  In  seven  patients  whom  I 
treated  in  this  manner  (of  which  four  cases  were  without  hereditary 
antecedents,  and  two  suffered  from  epileptiform  hysteria),  and  in  five 
other  patients  treated  similarly  at  the  Vienna  Lunatic  Asylum,  the  drug 
produced  no  permanent  good  effects.  Beigel,  Voisin,  and  Liouville  have 
since  arrived  at  a  similar  conclusion.  In  one  of  my  cases  (Wien.  Med. 
Presse,  6,  1867),  after  an  injection  of  0.01,  symptoms  of  poisoning  ap- 
peared, consisting  of  nausea,  vertigo,  redness  of  the  face,  painful  throb- 
bing in  the  temples,  general  exhaustion,  acceleration  of  the  pulse,  and 
great  thirst;  chemical  analysis  of  the  urine  showed  the  presence  of  sugar. 
These  symptoms  disappeared  after  rest  and  simple  treatment. 

Narcotics  must  be  cautiously  administered  in  this  affection.  I  have 
seen  one  patient  (loc.  cit.)  who,  after  great  excitement,  had  fifteen  to 
twenty  attacks  in  one  day;  his  excitement  and  cries  induced  me  to  give 
him,  for  tliree  days,  a  hypodermic  injection  of  0.01  of  morphine;  the  pa- 
tient then  became  more  quiet,  and  remained  free  from  the  epileptic 
seizures  for  six  months.  Quinine  is  sometimes  useful  in  intermittent 
epilepsy. 

We  may  finally  mention  Chapman's  plan  of  treatment,  in  which  a 
caoutchouc  tube  filled  with  ice-water  is  applied  to  the  back  of  the  patient 
(for  two  to  eighteen  hours,  according  to  the  circumstances  of  the  case), 
the  limbs  are  rubbed  while  plunged  in  warm  water,  and  are  then  placed 
in  dry  cloths.  These  operations  should  be  followed  by  exercise,  deep  in- 
spirations, etc.  Treatment  is  ineffectual  in  the  status  epilepticus;  Browne 
has  lately  observed  good  effects  from  the  cautious  employment  of  nitrite 
of  amyl  in  inhalations. 


DISEASES    OF    THE    NERVOUS    SYSTEM.  79 


CHAPTER  XXX. 

ECLAMPSIA    (acute   EPILEPSy). 

Under  the  generic  term  eclampsia  are  included  those  various  condi- 
tions which  have  also  been  called  acute  epilepsy,  on  account  of  their  great 
analogy  with  that  affection,  and  which  present,  as  a  common  characteristic, 
alternations  of  tonic  and  clonic  spasms,  with  loss  of  consciousness.  In 
the  absence  of  any  other  guide,  we  must  rely  upon  the  etiological  condi- 
tions for  the  differentiation  of  the  various  kinds  of  eclampsia.  We  shall 
therefore  study,  in  succession,  the  eclampsia  of  pregnant  and  puerperal 
women,  the  eclampsia  of  children,  toxic  eclampsia,  and  the  eclampsia  due 
to  contagious  and  miasmatic  influences. 

A. — Eclampsia  of  Pregnant  and  Puerperal  Women. 

This,  on  the  whole,  infrequent  affection  (one  case  in  five  hundred  preg- 
nancies) may  occur  in  the  last  two  or  three  months  of  pregnancy,  but 
much  more  frequently  during  delivery,  and  especially  in  the  periods  of 
dilatation  and  expulsion.  Primipara  are  most  exposed  to  the  disease 
(about  eighty  in  one  hundred  cases,  C.  Braun);  robust,  sanguine,  young, 
or  nervous  females  are,  as  a  rule,  more  liable  to  the  affection  than  feeble 
and  older  women.  Multipara,  who  have  previously  had  eclampsia,  some- 
times manifest  a  certain  predisposition  to  its  development  (Litzmann). 

Eclampsia  may  develop  suddenly  or  may  be  preceded  by  certain  pro- 
dromata.  The  latter  consist  of  an  unusual  agitation,  cephalalgia,  pains 
in  the  epigastrium  or  uterus,  a  feeling  of  heaviness  in  the  limbs,  illusions 
of  the  senses,  etc.  If,  in  addition  to  these  symptoms,  oedema  develops, 
especially  in  the  labia  majora  and  around  the  malleoli,  if  the  urine  con- 
tains albumen,  or  if  an  analysis  of  the  blood  shows  the  presence  of  car- 
bonate of  ammonia,  there  is  every  reason  to  fear  an  attack  of  eclampsia. 
(In  one  case  Oppolzer  and  Braun  predicted  its  appearance  two  days  in 
advance,  from  the  results  of  the  analysis  of  the  blood.)  An  attack  of 
eclampsia  presents  the  same  symptomatology  as  epilepsy,  and  we  may  there- 
fore omit  its  description. 

The  seizure  may  last  from  a  few  minutes  to  a  quarter  of  an  hour,  and 
is  followed  by  a  condition  of  coma.  The  disease  often  terminates  after  a 
single  convulsion;  in  those  cases  in  which  the  seizures  are  separated  by 
long  intervals,  each  attack  is  preceded  by  the  prodromata  to  which  we 
have  previously  called  attention.  In  severe  cases  the  patients  only  rally 
from  the  coma  to  fall  into  another  attack,  and  death  occurs  without  a  res- 
toration of  consciousness.  When  the  attacks  cease,  the  stage  of  coma 
often  continues  several  days  until  consciousness  and  the  functions  of 
special  sense  are  gradually  restored.  Memory  is  very  much  affected  in 
these  cases;  the  patients  do  not  know  that  they  have  been  confined,  and 
refuse  to  recognize  th^ir  offspring. 


80  CLINICAL    TREATISE    ON 

The  labor  pains  and  the  act  of  delivery  undergo  various  modifications  in  different 
cases.  If  the  paroxysm  occurs  during  the  first  period  of  labor,  the  uterus  is  contracted 
and  firm  to  the  feel  (although  this  circumstance  does  not  intiuence  the  dilatation  of  the 
cervix),  and  the  progress  of  labor  is  retarded.  When  the  eclamptic  attack  occurs  at 
the  moment  of  spontaneous  expulsion,  the  delivery  of  the  child  occurs  very  rapidly. 

There  is  often  no  trace  of  pains  when  the  paroxysm  begins,  but  the  eclampsia  pro- 
vokes pains,  and  the  delivery  of  the  child  therefore  is  almost  always  produced  prema- 
turely. Nevertheless,  the  eclamptic  attack  and  the  labor  pains  may  be  separated  by 
an  interval  of  several  weeks,  and,  even  when  the  pains  appear,  the  woman  is  almost 
always  delivered  of  a  dead  child.  The  death  of  the  foetus  is  not  attributable,  as 
Kiwisch  thinks,  to  circulatory  disturbances  developing  in  the  placental  vessels,  but 
rather  to  urremic  poisoning  affecting  the  child  through  the  blood  of  the  mother.  Upon 
several  occasions  considerable  quantities  of  urea  have  been  found  in  the  blood  of  the 
umbilical  cord  of  children  who  were  born  alive  and  whose  mothers  had  suffered  from 
ursemic  convulsions. 

The  termination  of  the  disease  is  extremely  variable.  Certain  women 
make  a  perfect  recovery;  but  others  have  hardly  escaped  the  danger  con- 
nected with  the  convulsions  when  another  presents  itself,  in  the  shape  of 
puerperal  fever,  for  which  the  exudative  processes  of  eclampsia  appear  to 
create  a  predisposition,  and  which  almost  always  proves  fatal  to  the 
patients.  Very  many  patients  succumb  to  the  eclamptic  attacks;  accord- 
ing to  C.  Braun,  among  forty-four  women,  nine  died  during  the  convul- 
sions and  five  from  the  sequences  of  puerperal  fever.  Death  may  occur 
from  asphyxia,  hremorrhage,  serous  infiltration  of  the  brain,  secondary 
cerebral  inflammation,  or  pulmonary  oedema.  A  much  more  important 
and  striking  fact,  which  is  often  observed  upon  autopsy,  is  the  alteration 
in  the  kidneys,  characterized  by  the  lesions  of  the  stage  of  hypeniemia  or 
exudation  in  Bright's  disease.  On  account  of  the  short  duration  of  the 
affection,  the  stage  of  fatty  degeneration  and  renal  atrophy  is  rarely 
observed. 

Authors  are  still  divided  in  opinion  with  regard  to  the  nature  of  eclamp- 
sia. As  Frerichs  first  showed  in  his  classical  treatise  (Die  Bright'sche 
Krankheit,  Braunschweig,  1851),  puerperal  eclampsia  is  only  observed  in 
those  women  who  have  suffered,  during  pregnancy,  from  Bright's  de- 
generation of  the  kidney.  In  consequence  of  the  disorders  in  the  urinary 
secretion,  the  albumen  of  the  blood  passes  into  the  urine,  while,  inversely, 
the  urea  of  the  blood  is  eliminated  by  the  urine  in  insufficient  quantity; 
hence  results  an  accumulation  of  urea  in  the  blood.  The  urea  is  then 
transformed  in  the  blood  into  carbonate  of  ammonia  by  the  action  of  an 
unknown  ferment,  and  the  poisonous  action  of  this  substance  upon  the 
nerve-centres  gives  rise  to  eclamptic  attacks.  The  presence  of  urea  in 
the  blood  does  not  suffice,  in  itself,  to  give  rise  to  the  symptoms  in  ques- 
tion, for,  according  to  the  experimental  researches  of  Frerichs,  the  injec- 
tion of  urea  into  the  vessels  does  not  produce  eclampsia.  Urea  is  often 
found  also  in  the  blood  of  patients  who  have  died  from  Bright's  disease 
without  having  presented  any  symptoms  of  unemia  during  life. 

According  to  Treitz,  the  saturation  of  the  blood  with  urea  in  Bright's 
disease  is  followed  by  its  elimination  throughout  the  intestinal  canal;  the 
substances  with  which  it  here  comes  in  contact  cause  its  transformation 
into  carbonate  of  ammonia,  which  passes  into  the  blood  and  produces 
eclampsia  from  ammonfemia. 

Spiegelberg  and  Gscheidlin  have  recenth'  succeeded  in  demonstrating 
the  presence  of  carbonate  of  ammonia  in  the  blood  of  an  eclamptic  patient 
(Arch.  f.  Gynaek.,  I.  Bd.).  Stockvis,  Spiegelberg,  and  Heidenhain  have 
produced  eclamptiform  attacks  in  animals  by  the  injection  of  carbonate 


DISEASES    OF   THE    NERVOUS    SYSTEM.  81 

of  ammonia  into  the  crural  vein  or  artery.  Rosenstein's  experiments 
(Virch.  Arch.,  Bd.  56,  1873)  were  attended  with  similar  positive  results, 
and  the  attacks  did  not  cease  until  the  spinal  cord  was  separated  from 
the  brain.  But  carbonate  of  ammonia  merely  gives  rise  to  eclamptiform 
attacks,  while  urtemic  poisoning  produces  convulsions,  delirium,  and  coma. 

The  theory  just  advanced  has  been  strongly  combated,  at  different 
times,  by  Kiwisch,  Scanzoni,  and  Krause,  who  regarded  the  coexisting 
Bright's  disease  as  merely  of  secondary  importance,  and  considered  it 
as  an  accidental  complication.  They  regarded  the  eclampsia  as  duo  rather 
to  the  mechanical  action  produced  upon  the  nerves  by  pregnancy  and 
parturition  (rigidity  of  the  lower  segment  of  the  uterus,  abundance  of 
the  amniotic  fluid,  transverse  presentations,  manual  interference,  abun- 
dant hfemorrhages).  Puerperal  eclampsia  should  therefore  be  regarded 
as  a  reflex  process,  like  the  reflex  epilepsy  produced  by  peripheral  irrita- 
tion. 

According  to  the  observations  collected  by  Braun  at  the  Vienna  Ma- 
ternity Hospital,  there  were  forty-four  cases  of  eclampsia  in  twenty-four 
thousand  confinements;  eight  other  cases  were  merely  accidental  compli- 
cations of  pregnancy,  two  being  due  to  hysteria,  four  to  habitual  epilepsy, 
one  to  capillary  cerebral  haemorrhage,  and  one  to  poisoning  with  carbonic 
oxide  gas.  Albuminuria  was  present  in  all  the  other  cases.  According 
to  the  observations  referred  to,  eclampsia  was  immediately  due  to  Bright's 
disease  in  the  very  large  majority  of  the  cases  in  question.  Degenera- 
tion of  the  kidneys  was  observed  in  a  considerable  number  of  autopsies, 
and  we  must  remark,  in  addition,  that  the  symptoms  of  urfemia,  which 
are  observed  in  animals  after  extirpation  of  both  kidneys,  present  the 
same  characteristics  as  the  acute  albuminuria  of  pregnant  females.  Even 
before  the  eclampsia  develops,  albumen  and  casts  are  found  in  the  urine 
of  pregnant  women.  The  appearance  of  casts  in  the  urine  is  especially 
important,  since  albumen  may  be  found  in  a  normal  pregnancy.  Blot 
gives  the  average  proportion  of  albumen  in  the  urine  of  those  patients 
who  suffer  from  albuminuria,  but  are  not  eclamptic,  as  thirty-three  per 
hundred,  and  in  eclamptics  as  about  seventy-four  per  hundred. 

Nevertheless,  the  renal  affection  does  not  appear  to  be  sufficient  to 
fully  explain  the  morbid  process  in  all  cases  of  the  affection.  In  certain 
instances  we  must  also  take  into  consideration  the  cerebral  ana?mia  follow- 
ing profuse  haemorrhages,  the  changes  in  the  blood  which  predispose  to 
puerperal  fever,  and,  in  a  very  large  proportion  of  cases,  we  must  admit 
the  existence,  as  in  epilepsy,  of  an  abnormal  excitability  of  the  nervous 
system.  The  latter,  under  the  influence  of  pregnancy  and  especially  of 
the  labor  pains,  or  in  consequence  of  the  compression  exercised  by  the 
uterus  upon  the  sacral  plexus,  will  give  rise  to  convulsions. 

From  a  diagnostic  point  of  view,  we  readily  comprehend  how  serious 
are  the  consequences  of  mistaking  eclamptic  attacks  for  other  paroxysms 
presenting  analogous  symptoms,  since  the  prognosis  and  treatment  are 
equally  affected  by  such  an  error.  A  careful  physician  will  not  readily 
mistake  urjemic  eclampsia  for  choL^emic  convulsions,  the  symptoms  of 
poisoning,  chorea  gravidarum,  and  the  syncopal  attacks  or  spasms  which 
are  sometimes  observed  during  pregnancy.  According  to  Bourneville's 
recent  investigations,  the  temperature  in  urfemia  becomes  progressively 
lower  until  death,  while  in  puerperal  eclampsia  it  follows  an  ascending 
course  (42°-43°  C).  A  sinking  of  the  temperature  curve  is  a  favorable 
prognostic  sign.  Hysterical  and  epileptic  convulsions  furnish  the  most 
frequent  source  of  error.  In  the  chapters  on  Hysteria  and  Epilepsy  we 
Vol.  II.— 6 


82  CLINICAL    TREATISE    ON 

have  given,  in  detail,  the  characteristic  signs  of  these  affections.  If  the 
patients  have  suffered  from  convulsive  attacks  previous  to  pregnancy,  and 
if,  after  having  become  pregnant,  they  present  similar  symptoms,  we  can 
readily  determine  their  true  character;  the  negative  results  of  the  urinary 
examination  (absence  of  albumen  and  casts)  are  of  great  importance.  The 
convulsive  affections,  which  we  have  previously  discussed,  do  not  present 
such  a  grave  prognosis  as  do  the  attacks  of  eclampsia.  The  former  do 
not  interrupt  pregnancy,  have  very  little  influence  upon  the  life  of  the 
foetus,  and  do  not  present  greater  dangers  to  the  mother  than  in  the  non- 
pregnant condition,  while  an  attack  of  eclampsia  seriously  threatens  the 
life  of  the  mother  as  well  as  that  of  the  child. 

The  physician  may  be  greatly  embarrassed  in  making  a  diagnosis,  in 
the  case  of  a  pregnant  woman  who  is  seized,  for  the  first  time,  with  a 
convulsion,  and  whose  previous  history  furnishes  no  clue.  If  no  oedema  is 
found  in  any  part  of  the  body,  or  no  abnormal  constituents  in  the  urine, 
we  will  be  forced  to  suspend  the  diagnosis  until  the  case  is  cleared  up  by 
the  appearance  of  new  attacks.  A  second  or  third  seizure  may  furnish 
decisive  results  on  the  part  of  the  urine,  and  relieve  the  physician  from 
annoying  uncertainty.  If  no  albumen  is  found  in  the  urine,  even  after 
several  attacks,  and  if  the  relatives  of  the  patient  positively  assert  that 
she  has  never  suffered  from  previous  epileptic  or  hysterical  attacks,  we 
must  take  into  consideration  the  possible  existence  of  a  disease  of  the 
brain  or  its  meninges,  of  typhoid  fever,  cholj^mia,  etc.,  and  we  must  look 
for  new  explanations  in  the  later  evolution  of  symptoms. 

The  prognosis  is  unfavorable  in  the  majority  of  eclamptic  affections. 
It  becomes  much  more  so  when  the  convulsions  follow  one  another  in 
rapid  succession,  when  the  patients  do  not  recover  consciousness  during 
the  intervals,  and  when  the  quantity  of  albumen  in  the  urine  increases 
after  each  attack.     The  mortality  varies  from  thirty  to  eighty  per  cent. 

The  prognosis,  with  regard  to  mortality,  is  much  more  unfavorable 
than  in  epilepsy,  though  much  more  favorable  with  regard  to  curability. 
In  the  eclampsia  of  pregnant  women,  abortion  or  premature  delivery  often 
occurs  (about  twenty-five  per  cent.,  Braun).  It  is  rare  that  the  convulsions 
cease  and  delivery  occurs  normally  without  the  supervention  of  eclamptic 
phenomena.  In  a  general  way  the  danger  is  greater  the  earlier  the  period 
of  pregnancy  in  which  the  attacks  begin,  and  a  repetition  of  the  convul- 
sions may  cause  the  death  of  mother  and  child  long  before  confinement. 

During  the  period  of  dilatation,  especially  when  this  is  slowly  consum- 
mated in  consequence  of  deformity  of  the  pelvis  or  of  a  vicious  position 
of  the  child,  a  stasis  of  venous  blood  occurs  in  the  veins,  and  the  progno- 
sis is  unfavorable.  The  prognosis  is  better  when  the  eclampsia  begins 
during  the  expulsive  period,  as  the  delivery  may  then  terminate  promptly 
and  the  convulsions  cease  immediately  or  shortly  after.  In  the  majority 
of  cases  the  convulsions  cease  after  delivery  is  accomplished.  During 
the  expulsive  period,  the  atony  of  the  uterus  may  give  rise  to  htemorrhage, 
and,  in  certain  cases,  instrumental  delivery  must  be  resorted  to.  Some- 
times the  attacks  continue  after  confinement,  and  in  certain  very  severe 
forms  they  only  develop  during  the  puerperal  condition  (from  the  first 
few  days  to  the  sixth  week).  At  times  the  patients  manifest  for  a  long 
time,  and  perhaps  even  during  their  whole  lives,  certain  psychical  disor- 
ders (melancholia,  mania,  imbecility),  which  vary  according  to  the  situa- 
tion and  intensity  of  the  secondary  modifications  of  the  puerperal  period. 
The  disease  may  also  be  followed  by  amaurosis,  hemeralopia,  hemiplegia, 
and  contractures.     If  the  symptoms  of  the  renal  affection  and  the  oedema 


DISEASES    OF    THE    NERVOUS    SYSTEM  83 

persist  for  several  weeks  after  confinement,  they  Avill  pass  into  a  chronic 
condition,  which  may  continue  a  long-time.  Nevertheless,  recovery  occurs 
more  readily  in  these  cases  than  in  Bright's  disease  due  to  other  causes. 

The  effects  of  eclampsia  upon  the  child  are  very  disastrous;  nearly 
half  of  the  children  die,  and  the  mortality  is  larger  the  earlier  the  period 
of  pregnancy  at  which  the  affection  has  developed.  Viable  infants,  at 
full  term,  are  not  endangered  by  the  urtemia  which  existed  in  the  mother, 
since  the  disease  is  never  hereditary.  In  one  of  Simpson's  cases,  however, 
albuminuria  was  detected  in  the  child  of  an  eclamptic  mother. 

In  the  treatment  of  uraemic  eclampsia  especial  importance  must  be  at- 
tached to  prophylactic  measures,  with  a  view  to  moderating  the  symp- 
toms of  Bright's  disease.  Beginning  hydrtemia  should  be  combated  by 
nourishing  diet,  tonics,  and  warm  baths.  In  order  to  neutralize  the  car- 
bonate of  ammonia  in  the  blood,  we  may  administer  benzoic  acid  (0.30- 
0.60  at  a  dose,  according  to  Frerichs),  lemon-juice,  and  tartaric  acid 
mixed  with  ice-water.  In  order  to  favor  the  elimination  of  urea  in  the 
urine,  we  would  recommend  the  plentiful  ingestion  of  fluids;  laxative 
enemata  are  useful  in  cerebral  congestions. 

The  most  energetic  measures  have  been  resorted  to  in  order  to  sup- 
press the  terrible  phenomena  of  eclampsia.  Venesection,  so  often  per- 
formed in  former  times,  is  much  less  frequently  employed  at  the  present 
time,  since  it  appears  to  increase  the  hydrfemia  and  exhaustion  of  the  pa- 
tients and  to  favor  the  development  of  puerperal  thromboses  and  pyaniiia. 
With  the  exception  of  cases  of  intense  cyanosis  and  vigorous  pulsation 
of  the  carotids,  or  in  patients  with  a  vigorous  constitution,  in  whom  vene- 
section, performed  at  the  proper  time,  may  prevent  the  occurrence  of 
a  cerebral  haemorrhage,  we  must  entirely  reject  the  practice  of  repeated 
bleedings  at  short  intervals. 

The  opiate  treatment  gives  good  results,  especially  after  delivery,  when 
the  attacks  occur  during  the  puerperal  period,  and  when  other  anaesthet- 
ics do  not  act  with  sufficient  promptness.  Opium  may  be  given  in  doses 
of  0.03-0.08,  and  morphine  in  doses  of  0.01-0.02.  When  the  drug  can- 
not be  swallowed,  we  prescribe  hourly  injections  per  rectum  of  fifteen  to 
twenty  drops  of  laudanum,  until  the  convulsions  have  ceased.  The  best 
effects  are  obtained  by  means  of  subcutaneous  injections  of  morphine 
(0.01-0.02).  If  the  patient  is  comatose,  opiates  should  not  be  adminis- 
tered, as  we  are  unable  to  sufficiently  control  their  toxic  effects.  Ac- 
cording to  the  experience  of  obstetricians,  the  inhalation  of  chloroform 
is  one  of  the  most  useful  measures  at  our  command.  It  may  be  given, 
according  to  Braun,  as  soon  as  the  increased  agitation  of  the  patient, 
the  increasing  rigidity  of  the  muscles  of  the  arm,  and  the  jactitation, 
indicate  the  beginning  of  a  convulsion;  the  inhalations  may  be  continued 
until  quiet  and  sleep  are  produced  (one  to  two  minutes).  During  the  at- 
tack, as  well  as  during  the  stage  of  coma,  the  anaesthesia  must  be  sus- 
pended and  fresh  air  be  permitted  to  enter  the  lungs.  The  administra- 
tion of  chloroform  may  even  be  employed  in  cases  of  persistent  trismus, 
and,  by  hastening  the  progress  of  delivery,  it  contributes  strongly  towards 
saving  the  life  of  the  infant.  Braun  reports  sixteen  cases  of  eclampsia, 
treated  with  chloroform  and  acids,  which  were  followed  by  complete  re- 
covery. When  delivery  is  retarded  in  women  suffering  from  Bright's 
disease,  Chailly  advises  (Union  Medic,  1855)  the  inhalation  of  a  small 
amount  of  chloroform  as  a  prophylactic  measure.  For  some  time  also 
hydrate  of  chloral  has  been  largely  employed  in  cases  of  eclampsia. 

Cold  applications  may  be  made  in  the  form  of  compresses  of  ice-water 


84  CLINICAL    TEEATISE    ON 

which  completely  cover  the  head).  This  is  more  useful  in  excited  patients 
than  the  application  of  leeches  to  the  mastoid  processes.  During  the 
paroxysms,  and  especially  during  the  stage  of  coma,  benefit  is  obtained 
from  cold  affusions  to  the  head,  the  patient  being  placed  at  the  edge  of 
the  bed. 

The  active  revulsive  measure  recommended  by  some  authors  (h?emo- 
spasia  (Junod's  boot),  tartar  emetic,  ammonia,  etc.)  are  not  followed  by 
any  marked  benefit.  We  have  previously  referred  to  the  precaution- 
ary measures  to  be  adopted  during  the  convulsions,  in  the  article  on  Epi- 
lepsy. In  a  case  of  puerperal  eclampsia,  published  by  Lange  (Prag. 
Vjschr.,  IV.  Bd.,  1868),  the  convulsions  began  before  delivery,  and  con- 
tinued into  the  puerperal  period,  despite  local  bleeding,  applications  of 
ice,  inhalations  of  chloroform,  and  injections  of  morphine.  Two  hundred 
and  forty-five  grains  of  defibrinated  blood  were  then  injected  into  one 
arm,  while  four  hundred  and  ninety  grains  of  blood  were  being  drawn 
from  the  other.  The  respirations  soon  became  easier,  the  cyanosis  dis- 
appeared, and,  although  another  slight  attack  occurred,  consciousness 
was  soon  restored,  and  the  patient  made  an  excellent  recovery. 


B. — Eclampsia  of  Children. 

The  eclampsia  of  children  and  of  the  new-born  presents  an  importance 
equal  to  that  of  eclampsia  parturentium,  but  its  nature  is  less  under- 
stood and  less  exactly  defined.  Under  this  term  are  included  the  varied 
convulsive  conditions  observed  in  children,  which  are  characterized  by  the 
occurrence  of  phenomena  dangerous  to  life,  and  attended  with  complete 
or  partial  loss  of  consciousness. 

The  symptoms  of  the  disease  are  often  preceded  by  certain  significant 
prodromata.  Among  these  we  may  mention  the  perverseness  of  the 
children,  a  marked  tendency  to  stumble,  sleep  disturbed  and  broken  by 
frightful  dreams,  grinding  of  the  teeth,  cries,  spasms  of  the  muscles  of  the 
face  and  eyes,  and  subsultus  tendinum.  The  eclamptic  attacks  develop 
after  a  longer  or  shorter  duration  of  these  prodromata  (though  some- 
times suddenly),  are  similar  to  those  occurring  in  adults,  and  are  man- 
ifested under  the  form  of  tonic  and  clonic  spasms,  attended  with  loss  of 
consciousness.  At  first  the  convulsions  are  almost  always  limited  to  cer- 
tain portions  of  the  body,  and  consciousness  is  partially  preserved  ;  at  a 
later  stage  it  disappears  completely,  and  the  convulsions  at  the  same 
time  increase  in  extent  and  intensity.  In  the  majority  of  instances  the 
trunk  is  affected  by  tonic  and  the  limbs  by  clonic  spasms.  The  intense 
cyanosis  of  the  face,  the  swelling  of  the  jugular  veins,  the  stertorous  and 
sometimes  intermittent  breathing,  and  the  frequent  and  small  pulse,  tes- 
tify to  the  serious  disturbances  occurring  in  the  organs  of  circulation  and 
respiration. 

The  duration  of  the  attacks  is  extremely  variable.  Sometimes  they 
terminate  quickly,  sometimes  they  continue,  with  intertuptions,  for  hours 
and  even  days,  consciousness  remaining  disordered,  and  the  little  patients 
being  excited  and  extremely  irritable.  The  eclampsia,  whether  partial  or 
general,  terminates  after  one  or  two  paroxysms,  or  it  may  be  divided  into 
a  series  of  attacks,  which  recur  more  or  less  frequently. 

In  the  cases  which  terminate  fatally  we  may  find  the  following  ana- 
tomical lesions:  htemorrhages  into  the  mucous  membranes,  oedema  and 
haemorrhages  into  the  brain  or  other  organs,  rupture  of  muscles,  luxations, 


DISEASES    OF    THE    NERVOUS    SYSTEM.  85 

and  even  fractures  (in  consequence  of  the  violence  of  the  convulsive 
movements). 

From  an  etiological  point  of  view,  the  majority  of  authors  regard  the 
existence  of  nervous  diseases  in  the  parents  and  hereditary  influence  as 
creating,  in  very  many  children,  a  predisposition  to  eclamptic  affections. 
As  the  convulsions  are  most  frequently  observed  during  the  period  of 
first  dentition,  the  development  of  the  teeth  has  been  looked  upon  as 
a  cause  of  the  disease,  but  this  hypothesis  has  very  little  foundation  in 
fact.  The  eclamptic  attacks  occur  during  that  period  in  which  the  child's 
brain  possesses  extreme  delicacy  of  structure  and  marked  excitability. 
Local  causes  (hyperasmia  or  cerebral  anaemia  following  diarrhoea),  as  well 
as  peripheral  irritations,  readily  give  rise,  therefore,  to  convulsive  symp- 
toms. 

Another  source  of  the  convulsive  seizures  in  children  is  found  in  the 
acute  exanthemata  (scarlatina,  variola,  rubeola),  which  develop  most  com- 
monly after  the  age  of  two  or  three  years.  The  stomachal  affections  of 
childhood  (milk  of  poor  quality,  undigested  food),  intestinal  affections 
(worms,  for  example,  which  are  not  found,  however,  in  infants),  and  dis- 
eases of  the  kidneys  (Bright's  degeneration  following  scarlet  fever,  the 
passage  of  calculi  through  the  kidneys  or  bladder),  may  also  act  as  causes 
of  eclamptic  attacks.  They  are  produced  in  nurslings,  though  less  fre- 
quently, by  mental  excitement  occurring  in  the  mother  or  nurse,  and  in 
older  children  they  may  be  due  to  emotional  causes.  Diseases  of  the 
brain  (meningitis,  acute  cerebral  tuberculosis,  cerebral  tumors)  may  also 
be  the  source  of  eclamptiform  phenomena;  finally,  the  latter  may  follow 
irritation  of  the  peripheral  nerves  (wounds,  pricks). 

With  regard  to  diagnosis,  we  must  endeavor  to  determine  whether 
the  affection  is  central  or  peripheral,  idiopathic  or  symptomatic,  a  distinc- 
tion which  it  is,  however,  impossible  to  make  in  many  cases.  How  often 
may  not  anatomical  changes  be  present  in  the  central  nervous  system, 
which  we  do  not  even  suspect,  much  less  detect  ?  If  we  are  able  to  find 
none  of  the  diseases  mentioned  above,  in  any  remote  part  of  the  body, 
which  may  act  as  the  source  of  irritation  to  the  nervous  centres,  we  may 
be  enabled,  after  prolonged  and  careful  observation,  to  determine  to  which 
category  the  case  in  question  belongs. 

We  have  several  times  referred,  in  the  preceding  chapters,  to  the 
characteristic  signs  of  the  various  cerebral  diseases  which  are  accompa- 
nied by  eclamptic  symptoms.  In  acute  hydrocephalus  the  convulsions 
are  usually  preceded  by  cerebral  phenomena  (cephalalgia,  pupillary  anom- 
alies, contracture  of  the  neck,  retardation  of  the  pulse,  retraction  of 
the  abdomen,  etc.),  the  symptoms  of  the  primary  disease  persisting  in  the 
intervals  of  the  attacks,  while  the  true  eclampsia  of  childhood  is  not,  as  a 
rule,  accompanied  by  the  above-mentioned  cerebral  symptoms,  and  pre- 
sents no  characteristic  phenomena  apart  from  the  convulsions.  In  the 
affection  which  was  described  in  detail  by  Elsaesser,  under  the  name  of 
craniotabes  (Der  weiche  Hinterkopf,  etc.,  Stuttgart,  1843),  and  which  is 
often  accompanied  by  eclampsia,  we  are  able  to  detect,  in  the  neighbor- 
hood of  the  lambdoid  suture,  certain  points  in  which  the  cranium  is  re- 
duced to  the  thickness  of  a  sheet  of  paper,  or  in  which  there  are  com- 
plete losses  of  substance  in  the  bones,  with  adhesion  of  the  dura  mater  to 
the  pericranium.  The  other  symptoms  of  this  affection  are  the  sensibil- 
ity of  the  head  to  contact  and  during  the  recumbent  posture,  insomnia, 
sparseness  of  the  hairs,  irritability,  and  convulsions  accompanied  by 
spasms  of  the  glottis.     One-half  of  these  cases  prove  fatal.     At  the  au- 


86  CLINICAL    TREATISE    ON 

topsy,  hyperaemia  and  inflammation  of  the  spinal  meninges  are  found  to 
be  present.  Craniotabes  is  a  form  of  rachitis  which  usually  develops 
towards  the  second  quarter  of  the  first  year,  while  the  eclamptic  convul- 
sions do  not  appear  before  the  third  quarter  (during  the  period  of  denti- 
tion, which  is  delayed  in  rachitic  patients). 

The  2)ro(/)iosis,  in  accordance  with  the  statements  previously  made,  is 
almost  always  very  grave.  It  is  most  unfavorable  in  central,  sympto- 
matic eclampsia,  and  the  disease  usually  proves  fatal  in  these  cases.  In 
idiopathic  eclampsia  a  large  number  of  the  patients  survive  and  recover 
completely,  but  various  sequences  of  the  disease  often  remain  permanent, 
such  as  contracture  of  the  limbs,  strabismus,  disorders  of  speech,  hemi- 
plegia, and  imbecility.  Frequency  of  the  attacks  or  repeated  relapses 
are  very  unfavorable  prognostic  elements.  Sometimes,  also,  the  disease 
may  terminate  in  habitual  epilepsy.  In  reflex  eclampsia  the  attacks  may 
subside  if  the  cause  be  removed  or  if  it  disappear  spontaneously. 

The  treatment  of  infantile  eclampsia  is  concerned  chiefly  with  prophy- 
laxis. Children  who  manifest  a  certain  tendency  to  the  development  of 
convulsive  movements,  or  whose  mothers  have  suffered  from  convulsions, 
should  be  placed  upon  a  generous  and  chiefly  animal  diet;  they  should 
sleep  in  well-ventilated  apartments,  and  be  restrained  from  precocious  in- 
tellectual exertions;  they  should  live  in  the  country,  and  be  subjected  daily 
to  moist  frictions  of  the  entire  body. 

In  light  attacks  we  may  employ,  as  sedative  measures,  enemata  of 
cold  water,  to  which  some  vinegar  has  been  added,  and  warm  baths.  In 
severe  cases,  and  when  the  children  are  more  advanced  in  years,  advantage 
is  derived  from  the  administration  of  chloral,  in  increasing  doses,  or  of 
inhalations  of  chloroform;  but  the  latter  should  only  be  employed  until 
the  muscles  are  relaxed,  and  must  not  be  pushed  to  the  production  of 
complete  anaesthesia.  When  manifest  symptoms  of  stasis  and  respiratory 
disorders  are  present,  we  may  prescribe  frictions  of  the  body  with  warm 
cloths,  cutaneous  revulsives,  irritating  enemata,  and  the  internal  adminis- 
tration of  a  little  wine  or  some  of  the  aromatic  infusions  with  a  few  drops 
of  tincture  of  musk.  When  there  is  danger  of  collapse,  the  majority 
of  authors  recommend  cold  aifusions  to  the  head  while  the  patient  is  in  a 
warm  bath.  In  teething  children,  the  English  physicians  often  practise 
incision  of  the  gums.  This  operation  will  hardly  facilitate  the  protrusion 
of  the  tooth,  but  its  effects  are  rather  due  to  the  haemorrhage  produced 
from  the  swollen  and  congested  gums  and  to  the  diminution  of  the  pres- 
sure to  which  they  are  subjected. 


C. — Toxic  Eclampsia. 

Experience  teaches  us  that  a  very  large  number  of  poisons  of  every 
description  may  give  rise  to  the  most  dangerous  attacks  of  convulsions. 
Certain  metallic  poisons,  irrespirable  gases,  and  poisons- of  organic  origin 
are  included  under  this  category.  Lead  occupies  the  most  prominent 
place  among  the  metallic  poisons,  but  lead  eclampsia  is  nevertheless  a  rare 
disease.  It  is  almost  always  associated  with  other  symptoms  of  chronic 
lead-poisoning  (colic,  arthralgia,  lead  paralysis,  delirium,  disorders  of 
the  special  senses,  and  maniacal  attacks),  and,  as  a  rule,  does  not  last 
more  than  a  few  days.  According  to  Tanquerel  des  Planches,  one-fifth 
of  the  patients  aifected  with  this   disease   recover;  Grisolle  lost  almost 


I 


DISEASES    OF    THE    NEEVOUS    SYSTEM.  87 

all  his  patients.  The  former  author  denied  the  existence  of  any  relation 
between  this  form  of  eclampsia  and  uraemia  or  albuminuria,  as  he  was 
unable  to  discover  in  his  patients  the  presence  of  albumen  in  the  urine 
or  any  lesions  in  the  kidneys.  More  recently  Rosenstein  (Schuchardt's 
Zeitschr.  f.  prak.  Heilk.,  4.  H.,  1867)  demonstrated,  by  a  series  of  experi- 
ments on  dogs  (the  animals  died  from  lead  amaurosis  and  eclampsia,  after 
the  prolonged  administration  of  acetate  of  lead),  that  chronic  lead- 
poisoning  produced  neither  albuminuria  nor  anatomical  changes  in  the 
kidneys;  that,  despite  less  abundant  diuresis,  no  carbonate  of  ammonia, 
and  only  a  very  small  proportion  of  urea,  was  found  in  the  blood;  that, 
after  the  death  of  the  animals,  chemical  analysis  demonstrated  the  pres- 
ence of  lead  in  the  brain;  and  that  cerebral  anaemia  must  be  regarded 
as  the  anatomical  cause  of  the  eclampsia.  In  lead  eclampsia,  in  the 
human  subject,  the  brain  has  been  found  of  a  dusky  color,  the  paren- 
chyma anaemic  and  sometimes  indurated,  and  the  ventricles  dilated; 
upon  chemical  analysis  the  sulphate  or  albuminate  of  lead  has  been 
found  in  the  cerebral  tissues. 

Antiphlogistic  measures  and  venesection  formerly  played  an  impor- 
tant part  in  the  treatment  of  this  disease.  In  these  cases  Stoll  pre- 
scribed opium,  especially  when  the  patient  suffered  from  delirium  and 
attacks  of  mania.  Tanquerel  resorted  to  the  administration  of  croton 
oil,  but  its  employment  produced  no  more  permanent  effects  than  the 
purgative  treatment  of  the  Charite.  At  the  present  time  the  treatment  is 
chiefly  S3^mptomatic,  consisting  of  local  bleedings,  cold  compresses  to  the 
head,  cold  affusions,  and  the  administration  of  opium  when  the  patient 
suffers  from  pain  and  delirium. 

In  poisoning  with  irrespirable  gases,  such  as  carbonic  oxide  and  car- 
buretted  hydrogen,  eclamptic  phenomena  also  make  their  appearance. 
In  these  cases  we  must  immediately  remove  the  patient  from  the  action 
of  the  deleterious  gases.  If  there  is  intense  congestion  of  the  brain,  we 
may  practise  venesection;  when  the  respiration  is  suspended,  we  must 
begin  artificial  respiration.  If  a  faradic  battery  is  readily  accessible,  we 
should,  according  to  Ziemssen,  faradize  the  phrenic  nerve  in  the  neck. 
In  conditions  of  sopor  and  cyanosis,  benefit  is  sometimes  derived  from 
cold  affusions  to  the  head,  frictions  of  the  entire  body,  and  enemata  of 
vinegar. 

The  vegetable  poisons  (prussic  acid,  coniine,  nicotine,  picrotoxin 
(the  extract  of  menispermum  cocculus),  cicuta  aquatica,  oenanthe  crocata) 
may  also  give  rise  to  eclamptiform  convulsions  combined  with  symp- 
toms of  tetanus  and  trismus.  The  symptomatology  and  treatment  of 
these  various  conditions  are  still  very  defective,  and  we  refer  for  further 
information  concerning  the  poisons  to  the  special  treatises  on  the  sub- 
ject. 

In  conclusion,  we  may  say  a  few  words  concerning  eclampsia  arising 
from  contagious  and  miasmatic  influences.  Eclampsia  sometimes  precedes 
the  development  of  the  acute  exanthemata,  but  it  quickly  ceases.  The 
eclampsia  is  much  more  severe  when  it  appears  at  the  height  of  the  af- 
fection, when  it  is  accompanied  by  high  fever  or  by  Bright's  disease,  as 
in  the  advanced  stages  of  variola  and  scarlatina,  or  by  pvaemia  and 
meningitis,  as  in  variola.  Eclamptic  symptoms  may  also  appear  in  the 
first  stage  of  typhoid  fever,  in  acute  articular  rheumatism,  and  in  facial 
erysipelas,  although  these  affections  are  uncomplicated  with  meningitis  or 
encephalitis.  In  some  cases  metastatic  foyers  are  found  in  the  brain,  or 
there  is  merely  a  slight  serous  infiltration  of  the  parenchyma,  a  fluid  con- 


'6S  CLINICAL    TREATISE    ON 

dition  of  the  blood,  or  relaxation  of  the  muscular  tissue  of  the  heart. 
Often,  howev'er,  none  of  these  changes  are  observed,  and  we  are  left  in 
complete  ignorance  of  the  cause  of  the  convulsions.  Eclampsia  also 
occurs  in  pseudo-membranous  angina,  in  oedema  glottidis,  and  in  spasm 
of  the  glottis  in  children  (thymic  asthma).  In  these  cases  the  convul- 
sions may  be  attributed  to  the  obstruction  to  the  flow  of  arterial  blood 
to  the  brain. 

Certain  abdominal  diseases,  acute  atrophy  of  the  liver,  and  the  pas- 
sage of  renal  or  biliary  calculi  may  also  be  accompanied  by  eclampsia. 
Finally,  the  severe  intermittent  fevers  of  certain  districts  are  accompanied 
by  eclamptic  attacks,  which  yield  to  large  doses  of  quinine. 


DISEASES    OF    THE    NERVOUS    SYSTEM.  89 


CHAPTER  XXXI. 

TETANUS. 

Tetanus  is  a  motor  spinal  neurosis,  characterized  by  an  exaggerated 
excitability  of  the  motor  functions  and  of  reflex  action,  with  alternations 
of  muscular  contractions  of  a  convulsive  or  tonic  character,  and  running 
a  rapid  and  very  frequently  fatal  course. 

Owing  to  our  complete  ignorance  of  the  anatomical  lesions  of  tetanus, 
an  exaggerated  importance  has  been  attached  to  the  etiological  conditions 
in  classifying  the  disease  into  its  various  forms.  Tetanus  has  been  di- 
vided into  traumatic,  rheumatic,  hysterical,  inflammatory,  toxic,  inter- 
mittent, endemic,  and  tetanus  neonatorum.  This  classification  groups  to- 
gether entirely  dissimilar  types,  and  embraces  hysterical  tetanus,  which  is 
merely  a  tonic  muscular  spasm,  of  a  rapid  and  benign  course,  and  inter- 
mittent tetanus  (tetany),  which  is  a  partial  reflex  spasm,  due  to  various 
affections,  and  possessing  no  gravity. 

In  the  following  remarks  we  shall  consider  tetanus  and  trismus  con^ 
jointly,  since  they  are  nearly  always  combined. 


Pathological  Anatomy. 

Rokitansky  first  showed,  in  his  important  investigations  upon  the 
structure  of  the  connective  tissue  of  the  nervous  centres  (1856),  that  in 
tetanus  the  alterations  in  the  connective  tissue  chiefly  consisted  of  a  de- 
posit of  a  semi-fluid,  grayish  colloid  substance,  which  abundantly  infil- 
trated the  tissues  of  the  cord,  separated  them  from  one  another,  and  ap- 
peared, upon  cut  section,  like  white  bands  upon  an  opaque,  grayish  back- 
ground. In  less  advanced  forms  the  microscope  reveals  the  presence  of  a 
delicate,  semi-liquid  substance,  strewn  with  small  granular  nuclei,  a  vari- 
cose and  disintegrated  condition  of  the  nerve-fibres,  fatty  granules,  and 
colloid  and  amyloid  corpuscles.  A  few  years  later  Demme's  observations 
(Beitr.  zur  path.  Anat.  des  Tetanus,  1859)  confirmed  these  statements,  and 
showed  that  the  usual  sites  of  this  proliferation  of  connective  tissue  are, 
in  addition  to  the  cord,  the  medulla  oblongata  with  the  fourth  ventricle, 
the  crura  medulla  ad  cerebellum  et  ad  corpora  quadrigemina. 

According  to  the  researches  of  Lockhart  Clarke  (Med.-Chir.  Trans., 
48,  1865)  upon  nine  cases  of  tetanus,  inflammatory  changes  with  softening 
(granular  disintegration)  occur  in  the  gray  substance  of  the  cord,  espe- 
cially around  the  central  canal;  the  gray  horns  had  often  lost  their  sym- 
metry, and  their  dilated  vessels  were  surrounded  by  an  abundant  exuda- 
tion, containing  nuclei  and  the  debris  of  nerve-fibres. 

Dickinson  has  described  similar  changes  (eod.  loc,  51,  1868)  in  a  case 
of  traumatic  tetanus  terminating  in  death  at  the  end  of  eight  days.  Mi- 
chaud  (Arch,  de  Physiol.,  1,  1872)  has  found,  in  one-quarter  of  the  cases 
of  traumatic  tetanus,  the  following  lesions  of  a  subacute  central  myelitis: 


90  CLINICAL    TREATISE    ON 

a  reddish  color  of  the  parenchyma  of  the  cord;  small  spots  of  a  semi-liquid 
consistence,  with  abundant  nuclear  proliferation  into  a  finely  granular 
substance,  in  the  white  matter  as  high  up  as  the  pons,  and  especially  in 
the  central  portions  of  the  gray  columns.  These  lesions  appeared  to  re- 
sult from  an  exudation  which  was  furnished  by  the  enormously  dilated 
vessels,  and  were  especially  observed  in  the  neighborhood  of  the  latter. 
The  nuclear  proliferations  were  abundant  in  the  central  canal  (which  may 
be  entirely  obliterated)  and  in  the  posterior  commissure.  The  lumbar  re- 
gion M'as  most  seriously  involved;  in  one  case  a  subacute  spinal  menin- 
gitis was  also  present.  With  regard  to  the  peripheral  nerves,  extravasa- 
tions into  the  neurilemma  were  found  in  two  sciatic  nerves;  in  two  cases 
there  was  diminution  of  the  myeline  with  abundant  proliferation  of  the 
nuclei  in  the  sheath  of  Schwann.  Hayem  has  recently  studied  two  cases 
of  tetanus  (Arch,  de  Physiol.,  1874)  in  which  he  found  a  colloid  exudation 
into  the  white  and  gray  substance  of  the  cord,  and,  in  one  case,  swelling 
of  the  nerve-fibres  and  also  of  the  nerve-cells. 


Symptomatology. 

Tetanus  rarely  attacks  all  parts  of  the  muscular  system  simultaneously. 
As  a  rule,  the  paroxysm  is  preceded  by  certain  symptoms,  such  as  chills, 
a  feeling  of  oppression,  painful  twinges  in  the  neck,  stiffness  of  certain 
muscles,  lancinating  pains  starting  from  the  wound,  yawning,  difficulty  in 
deglutition  and  in  speech.  These  prodromata  may  last  a  few  days  or 
hours;  the  muscles  of  the  jaw  are  then  seized  with  a  tonic  spasm,  which 
afterwards  extends  to  the  neck,  thorax,  abdomen,  and  extremities.  At 
this  time  the  muscles  are  almost  always  as  rigid  as  wood,  but  in  some 
cases  this  rigidity  is  less  pronounced.  It  does  not  always  affect  all  the 
muscles  to  the  same  extent,  and  it  often  passes  from  one  to  the  other. 
The  limbs  are  more  often  extended  than  flexed.  The  facial  muscles  are 
not  free  from  these  symptoms.  During  the  periodical  exacerbation  of  the 
spasms,  the  features  assume  an  expression  of  pain  or  sardonic  laughter, 
the  brow  and  eyebrows  frown,  the  gaze  is  fixed,  and  the  lips  are  drawn 
apart  and  expose  the  teeth,  the  tongue  being  often  caught  between  them. 

At  a  more  advanced  stage  of  the  disease  the  body  may  be  arched  with 
the  convexity  forwards  (opisthotonos).  The  reverse  direction  (empros- 
thotonos)  is  very  rare,  having  occurred,  according  to  Friedreich,  only  three 
times  in  five  hundred  and  twenty-two  cases,  and  the  lateral  curvature 
(pleurosthotonos)  only  once.  Sometimes  the  rigid  body  forms  a  perfectly 
straight  line  (orthotonos).  Opisthotonos,  which  is  the  most  frequent 
form,  is  often  accompanied  by  lancinating,  constricting  pains  in  the  back 
or  hypogastrium,  which  are  indicated  by  the  cries  of  the  patient.  The 
contractions  may  be  so  violent  in  certain  places  that  they  produce  rupture 
of  the  muscles,  especially  of  their  primitive  fibrillse  (Bowftian,  Todd).  The 
muscular  fibres  then  present  transverse  ruptures,  without  lesion  of  the 
sarcolemma.  In  one  case  of  tetanus  (strychnine  poisoning  in  a  suicide, 
nineteen  years  of  age)  tho  cardiac  muscle  was  apparently  healthy;  but  I 
found,  in  various  places,  numerous  transverse  ruptures  of  the  muscular 
fibres,  with  hremorrhagic  extravasations,  some  of  which  were  punctate, 
while  others  presented  a  beautiful  appearance,  like  branching  coral. 

In  the  majority  of  cases  the  muscular  spasms  are  not  alone  manifested 
during  the  day,  but  sometimes  increase  in  intensity  during  the  night. 
During  the  paroxysms  i;he  voluntary  movements  are  entirely  abolished. 


DISEASES    OF    THE    NERVOUS    SYSTEM.  91 

but  they  reappear  in  the  intervals  of  the  attacks.  The  remissions  may  be 
complete,  or  slight  spasms  may  occur  during  the  intervals.  The  mere  in- 
tention to  execute  a  movement  often  suffices  to  produce  a  spasm.  They 
are  also  excited  by  the  slightest  irritation,  such  as  a  touch,  a  shock  com- 
municated to  the  bed,  or  a  gentle  current  of  air.  Consciousness  and  the 
special  senses  undergo  no  modification  during  the  paroxysms.  This  dis- 
tressing situation  plunges  the  patients  into  a  condition  of  anguish  and 
oppression.  They  are  usually  deprived  of  sleep,  the  convulsive  seizures 
preventing  repose.  In  the  more  favorable  cases,  in  which  the  muscles 
grow  quiet  under  the  influence  of  a  calm  sleep,  the  muscular  rigidity  re- 
sumes its  original  violence  when  the  patients  awake. 

Sensibility  presents  various  disorders  in  tetanus.  At  the  onset,  pains 
occur  in  the  neck,  back,  epigastrium,  or  in  the  muscles  which  are  the  seat 
of  the  convulsions;  sometimes  they  appear  in  distant  parts,  and  radiate 
along  the  trunks  of  the  nerves  or  nerve-roots.  In  two  cases  observed  by 
Demme,  diminution  of  sensibility  to  contact  and  pain  occurred,  with 
abolition  of  sensibility  to  temperature. 

Profound  modifications  of  respiration  and  circulation  are  also  notice- 
able. The  respiratory  muscles  are  affected,  in  great  part,  by  the  tonic 
spasms,  and  the  automatism  of  the  respiratory  movements  is  maintained 
by  the  diaphragm.  Respiration  is  usually  short,  labored,  and  inter- 
rupted; during  the  paroxysms  it  is  difficult  and  intermittent,  followed  by 
symptoms  of  dyspnoea,  oppression,  lividity  of  the  skin,  perspiration,  and 
miliary  eruptions.  When  the  paroxysm  has  passed,  the  respiration  becomes 
deeper  and  slower,  and  resumes  its  normal  rhythm  during  the  remissions. 
As  a  rule,  the  cardiac  movements  are  also  affected.  The  pulse  is  frequent 
and  full,  and  often  intermittent;  when  severe  paroxysms  follow  one  an- 
other in  rapid  succession,  it  becomes  small  and  fluttering.  In  a  case 
observed  by  Howship,  the  heart  was  found  strongly  contracted  and  firm 
at  the  autopsy  (performed  eleven  hours  after  death). 

The  voice  becomes  more  or  less  harsh  and  hoarse;  the  speech  loses  its 
timbre,  and  in  some  cases  it  is  unintelligible.  Deglutition  is  almost 
always  embarrassed  from  the  beginning,  and  is  sometimes  accompanied  by 
a  sensation  of  ulceration  in  the  pharynx.  The  mouth  is  dry,  the  tongue 
coated,  the  saliva  viscid,  thirst  increased,  and  the  appetite  diminished. 

Constipation  is  a  frequent  symptom  in  tetanus,  and  is  often  accom- 
panied by  flatulence  and  tenesmus. 

But  in  certain  cases  some  of  the  symptoms  referred  to  may  be  due  to 
the  remedies  which  are  employed.  The  urinary  secretion  may  be  normal; 
if  dysuria  and  anuria  are  present,  the  perspiration  will  be  more  abundant. 
The  urine  is  usually  alkaline,  and  sometimes  contains  sugar  (Demme);  the 
earthy  phosphates  are  increased  in  quantity,  the  urea  diminished;  albu- 
men is  merely  present  in  minute  traces.  As  Wunderlich  first  showed, 
and  as  the  researches  of  Billroth,  Fick,  Ebmeier,  Erb,  Ferber,  and  Ley- 
den  have  since  confirmed,  a  considerable  elevation  of  temperature  some- 
times occurs  in  tetanus  (especially  in  the  last  stage),  and  at  times  to  such 
a  height  as  is  rarely  seen  in  febrile  diseases  (43°-44°  C,  in  one  case  even 
as  high  as  44.7°);  according  to  Wunderlich,  this  may  be  followed,  after 
death,  by  a  further  rise  of  several  tenths  of  a  degree.  The  miliary  erup- 
tions occur  without  rise  of  temperature.  Nevertheless,  even  in  severe 
cases  of  tetanus,  we  usually  observe  only  subfebrile  temperature,  and, 
whenever  it  exceeds  the  lower  grades  of  febrile  movement,  we  must  re- 
gard it  as  indicative  of  the  existence  of  some  complication.  The  excessive 
temperatures  to  which  we  have  referred,  as  well  as  those  observed  in  acute 


92  CLIlSriCAL    TREATISE    ON 

lesions  of  the  brain  and  cervical  cord  (Brodie),  indicate,  according  to 
Wunderlich,  that  the  brain  is  the  seat  of  moderating  centres,  a  paralysis 
of  which  will  cause  a  morbid  increase  of  the  processes  of  calorification. 

The  different  varieties  of  tetanus  present,  with  some  slight  modifica- 
tions, the  same  symptomatology.  In  trismus  and  tetanus  of  the  new- 
born, certain  characteristics  are  found  peculiar  to  the  conditions  of  the 
first  periods  of  life.  The  tetanus  of  the  new-born  appears  within  five  to 
six  days  after  the  separation  of  the  funis.  It  is  preceded  by  certain  pro- 
dromata  (fretful  sleep,  isolated  convulsions,  relaxation  of  the  features,  re- 
fusal of  the  breast  on  account  of  the  inability  to  nurse).  The  paroxysms 
usually  begin  with  trismus,  contortions  of  the  face,  and  disorders  of  deglu- 
tition. The  tonic  spasms  then  extend  to  the  neck,  back,  the  respiratory 
muscles,  and  the  limbs.  Reflex  excitability  is  so  much  increased  that 
simple  contact,  or  a  movement  of  deglutition,  produces  convulsions  of  sev- 
eral minutes'  duration,  whicli  recur  spontaneously  with  increasing  vio- 
lence and  progressively  shorter  remissions.  The  disease  almost  always 
terminates  fatally  in  two  to  three  days,  with  symptoms  of  collapse. 

In  conclusion,  we  may  say  a  few  words  with  regard  to  the  affection 
known  as  tetany.  This  disease  appears  under  the  form  of  circumscribed 
tonic  spasms,  attacking  paroxysmally  the  different  muscles  of  the  limbs. 
It  is  characterized  by  its  intermittence,  the  symmetrical  affection  of  the 
muscles,  and  the  cessation  of  the  spasm  when  the  arteries  are  compressed 
(Trousseau).  In  two  cases  Erb  has  succeeded  (Arch.  f.  Psych.,  IV.  Bd., 
1873),  by  acting  upon  the  spinal  nerves,  in  producing  tetanus  upon  clo- 
sure of  the  cathode  with  comparatively  weak  currents,  as  well  as  at  the 
opening  of  the  anode.  (This  is  the  first  time  in  which  these  facts  were 
observed  in  the  human  subject.)  This  morbid  excitability  of  the  spinal 
centre  generally  disappears  under  treatment. 


Etiology. 

Tetanus  occurs  not  only  in  man,  but  also  in  the  lower  animals.  Thus, 
in  the  tropics,  in  which  the  disease  is  more  frequent,  cattle  and  horses  are 
subject  to  a  very  fatal  form  of  this  affection.  If  we  disregard  these  en- 
demic foyers  of  the  torrid  zone,  and  those  occurring  in  certain  wars,  we 
•will  find  that,  under  ordinary  conditions,  tetanus  is  a  comparatively  rare 
disease. 

Among  239,911  patients  in  the  Vienna  General  Hospital,  there  were  50  cases  of 
tetanus,  or  .308  per  1,000.  In  Guy's  Hospital  there  were  73  cases  of  tetanus  among 
113,030  patients,  or  .63  per  1,000.  In  Bombay,  however,  Peat  found  195  cases  of 
tetanus  among  36,719  patients,  or  7.3  per  1,000. 

With  regard  to  age,  experience  teaches  us  that  the  disease  is  most  frequent  from 
the  tenth  to  the  thirtieth  years  (39.2  per  cent. ,  according  to  Thamhayn).  Men  are  much 
more  predisposed  to  this  affection  than  women.  Among  the  50  cases  of  tetanus  oc- 
curring in  the  Vienna  Hospital,  there  were  37  men  and  13  women.  (Thamhayn  found 
329  men  and  68  women  among  397  cases. )  The  frequency  of  the  disease  is  also  influ- 
enced by  race  ;  in  Peat's  statistics,  11,939  natives  furnished  161  cases  of  tetanus,  115 
of  which  proved  fatal ;  among  2,733  Europeans  there  were  31  cases  and  15  deaths. 
The  natives  are,  therefore,  not  only  more  subject  to  tetanus  than  Europeans,  but  the 
disease  also  proves  much  more  fatal  to  the  former. 

The  constitution  and  habits  of  life  do  not  appear  to  play  an  important 
part  in  the  etiology  of  this  affection.  The  influence  of  climatic  and  at- 
mospheric conditions  also  seem  to  have  been  exaggerated.     Certain  mill- 


I 


DISEASES    OF    THE    NERVOUS    SYSTEM.  93 

tary  surgeons  have  observed  a  large  number  of  cases  of  tetanus,  while, 
during  other  wars,  despite  considerable  changes  in  temperature  and 
numerous  wounds  and  operations,  very  few  cases  have  been  seen.  In 
tropical  regions,  in  which  the  changes  of  temperature  are  so  marked, 
tetanus  is  usually  as  rare  as  in  temperate  zones;  but,  under  the  influence 
of  unknown  conditions,  it  suddenly  attacks  human  beings  as  well  as  the 
lower  animals,  whether  living  upon  the  mountains  or  in  the  valleys  and 
plains,  in  moist,  dry,  hot,  or  temperate  localities.  The  epidemics  are 
variable,  sometimes  benign,  sometimes  virulent  in  character.  Apart  from 
exposure,  there  are  other  etiological  conditions  which  may  give  rise  to 
this  disease.  It  may  be  classified  as  rheumatic,  traumatic,  toxic,  and  te- 
tanus neonatorum.  The  large  proportion  of  cases  are  caused  by  injuries 
of  the  peripheral  nerves,  due  to  compression,  wounds  of  various  kinds, 
complicated  fractures,  opening  of  abscesses,  amputations  of  limbs,  or 
operations  upon  various  portions  of  the  body. 

Tetanus  may  also  occur  after  central  lesions  (falls  upon  the  head  or 
back,  without  appreciable  external  injury).  The  reflex  stimulation  of 
the  spinal  system  may  be  produced  and  maintained  by  an  irritation  of 
the  sensory  fibres,  proceeding  from  the  periphery  or  from  the  internal 
organs.  Those  forms  which  have  received  the  name  of  idiopathic  tetanus 
will  usually  be  found,  upon  careful  examination,  to  have  developed  from 
some  internal  traumatic  origin.  Tetanus  is  thus  produced  by  parturi- 
tion, uterine  affections,  intestinal  irritation,  and  inflammatory  exudations 
which  have  irritated  the  pneumogastric  or  phrenic  nerves.  I  will  here 
mention  an  interesting  case  of  tetanus,  developing  during  the  resolution 
of  a  pneumonia,  which  I  observed  in  the  Vienna  General  Hospital. 

A  patient,  suffering  from  pneumonia  of  the  right  lung,  took  a  simple  enema 
(about  the  eleventh  day  of  the  di.«ease)  in  order  to  relieve  constipation  of  the  bowels, 
which  had  lasted  several  days.  After  the  enema,  he  complained  of  a  pain  in  the  anus, 
which  became  more  intense  at  the  end  of  the  second  day.  When  pressure  was  made 
upon  the  coccygeal  region,  which  was  spontaneously  painful,  reflex  contractions  of 
the  gluteal  muscles  were  produced  ;  the  pulse  was  one  hundred.  Despite  the  im- 
mediate administration  of  the  extract  of  cannabis  indica  and  then  of  large  doses  of 
opium,  tetanic  spasms  occurred  during  the  night,  followed,  upon  the  next  day.  by  tris- 
mus and  opisthotonos,  with  a  pulse  of  one  hundred  and  fifty-two,  but  without  loss  of 
consciousness.  The  patient  died  upon  the  following  day.  The  lesions  found,  upon 
autopsy,  were  serous  imbibition  of  the  brain,  reddish-brown  coloration  of  the  cere- 
bral cortex,  the  lower  lobe  of  the  right  lung  hepatized  and  friable,  the  heart  con- 
tracted. The  veins  of  the  anus  were  greatly  dilated  ;  about  two  centimetres  above 
the  anal  orifice  was  an  ulceration  as  large  as  a  three-cent  piece,  with  poorly  defined 
borders.  The  spinal  meninges  were  injected,  the  cord  projected  above  the  cut  sec- 
tion, and  was  strewn  with  a  grayish,  transparent  substance,  which  increased  in  quan^ 
tity  from  below  upwards.  The  tetanus  was  probably  a  complication  of  the  rectal  ul- 
ceration. 

Tetanus  occurs  most  commonly  during  the  period  of  the  cicatrization 
of  wounds.  According  to  Watson,  it  is  more  frequent  in  complicated 
wounds  and  in  losses  of  substance,  attended  with  arrest  of  suppuration, 
than  in  recent  and  simple  wounds.  As  a  rule,  the  violence  of  the  symp- 
toms bears  no  relation  to  the  severity  of  the  local  affection.  The  time 
which  elapses  between  the  receipt  of  the  injury  and  the  development 
of  tetanus  is  also  extremely  variable.  Among  seven  hundred  cases  col- 
lected by  Thamhayn,  six  hundred  and  three  were  traumatic  and  ninety- 
seven  idiopathic.  Toxic  tetanus  is  produced  by  the  administration  of 
strychnine  and  brucine,  and  the  poison  is  either  carried  by  the  blood  to 
the  central  nervous  system   or  is  applied   directly  to  the  cord,  as  in  ex- 


94  CLINICAL    TREATISE    ON 

periments  upon  animals.  After  the  destruction  of  the  cord,  strychnine 
produces  neither  spasms  in  the  limbs  nor  violent  contractions  of  the 
intestines.  If  the  lesion  of  the  cord  is  only  partial,  the  tonic  spasms  will 
occur  in  those  muscles  which  are  connected  with  the  intact  portions. 
A  transverse  incision  through  the  posterior  columns  will  prevent  the 
manifestation  of  the  tetanic  spasms.  If  the  posterior  roots  of  all  the 
spinal  nerves  are  cut  before  the  animal  is  poisoned  with  strychnine,  no 
spasms  will  follow  irritation  of  the  skin.  Decapitation  of  the  animals 
before  poisoning,  or  the  extirpation  of  the  medulla  oblongata,  does  not 
prevent  the  occurrence  of  reflex  spasms.  The  application  of  the  poison 
to  the  peripheral  nerves  alone  produces  no  effect. 

The  tetanizing  action  of  strychnine  varies  with  equal  doses,  and  evidently  depeüds 
upon  the  force  of  resistance  of  the  spinal  system.  Taylor  mentions  the  case  of  a 
physician  who  died  after  having  taken  0.03  of  strychnine.  Christieon  regards  this 
dose  as  fatal  when  it  is  introduced  into  the  blood  through  the  surface  of  a  wound. 
0.2  has  been  known  to  cause  opisthotonos,  though  not  followed  by  death.  Watson 
refers  to  two  patients,  each  of  whom  took  0.07  of  strychnine  by  mistake;  one  of 
them  suffered  from  well-marked  tetanus,  while  the  other  merely  complained  of  ver- 
tigo, tremor,  disturbances  of  speech  and  deglutition,  and  spasms  in  the  neck.  Ac- 
cording to  Christison,  we  must  regard  the  absence  of  tetanic  symptoms,  during  the 
fir.st  two  hours  after  the  ingestion  of  a  preparation  of  nux  vomica,  as  a  favorable  sign. 
Van  Hasselt,  after  an  exhaustive  review  of  medical  literature,  found  only  one  case  of 
tetanus  which  did  not  occur  within  three  hours  after  the  administration  of  the  strych- 
nine. This  patient,  however,  was  an  opium  eater,  in  whom  the  influence  of  the  nar- 
cotic perhaps  favored  recovery.  According  to  Andral  and  Magendie,  the  action  of 
brucine  is  from  twelve  to  thirty-two  times  weaker  than  that  of  strychnine. 

Patients  who  were  poisoned  with  strychnine  have  been  known  to  re- 
cover, even  after  repeated  convulsions  and  attacks  of  asphyxia.  In  these 
cases  the  convulsions  diminish  in  frequency  and  intensity,  and  finally 
disappear  completely,  being  followed,  for  a  long  time,  by  exhaustion, 
paresis  of  the  limbs,  and  intellectual  torpor.  In  more  severe  cases  the 
spasms  of  the  jaw,  back,  and  limbs  increase  rapidly  in  intensity,  the  eyes 
protrude,  the  pupils  are  markedly  dilated  and  do  not  contract  under  the 
influence  of  light,  the  action  of  the  heart  becomes  weak  and  irregular, 
the  respiration  becomes  labored,  finally  terminating  in  cyanosis,  and  the 
sense-perceptions  and  consciousness  become  less  clear.  There  are  usu- 
ally several  paroxysms,  and  death  occurs  at  the  end  of  a  few  minutes  to 
a  half  hour,  with  symptoms  of  asphyxia  and  general  collapse. 

Tetanus  neonatorum  is  often  of  a  traumatic  character,  and  is  due  to  an 
inflammation  of  the  umbilicus  after  the  detachment  of  the  funis.  The 
frequency  of  tetanic  spasms  in  these  conditions  is  important  from  an 
etiological  point  of  view.  But  it  would  be  going  too  far  to  attribute  all 
cases  of  trismus  and  tetanus  neonatorum  to  affections  of  the  umbilicus. 
Robust  infants  tolerate  disorders  of  this  character  without  the  slightest 
inconvenience.  Sudden  exposure  and  wounds  (circumcision,  according 
to  Loewenstein)  may  also  give  rise  to  tetanic  spasms  in  infants.  Numer- 
ous cases  have  been  reported  of  hyperaemia,  of  serous  infiltration  of  the 
brain  or  cerebral  meninges,  of  meningeal  apoplexy,  stasis  in  the  venous 
sinuses,  hypertemia  of  the  spinal  meninges,  pulmonary  congestion,  etc., 
in  which  tetanus  (probably  secondary)  was  observed  during  life.  Micro- 
scopical examination  of  the  nerve-centres  has  rarely  been  made  in  these 
cases.  The  disease  occurs  most  frequently  from  the  fifth  to  the  twelfth 
day  after  birth ;  it  then  becomes  rarer  up  to  the  age  of  five  years. 


DISEASES    OF    THE    NERVOUS    SYSTEM.  95 


Nature  of  Tetanus. 

The  clinical  symptoms  and  the  data  afforded  by  pathological  anatomy- 
concur  in  demonstrating  that  the  spinal  cord  is  involved  in  the  affection 
under  consideration.  The  opinion  has  been  entertained  that  trismus  and 
tetanus  are  merely  functional  disorders,  due  to  exaggerated  reflex  action 
without  any  anatomical  lesions.  The  existence  of  the  lesions  in  vs^ounded 
nerves,  which  may  sometimes  be  traced  to  the  cord,  gave  rise  more  re- 
cently to  the  reflex  theory,  while,  on  the  other  hand,  the  theory  which 
attributed  to  the  blood  the  initial  pathogenic  role  also  found  distinguished 
advocates. 

Upon  examining  these  various  opinions,  it  becomes  evident  that  the 
theory  of  reflex  irritation  furnishes  us  with  the  most  satisfactory  explana- 
tions of  this  affection.  The  action  of  cold  or  of  a  wound  of  the  periph- 
eral nerves  causes,  by  reflex  means,  a  condition  of  vascular  erethism  in 
the  spinal  system,  and  this  condition  will  be  produced  more  readily  when 
the  nerves  are  very  sensitive  or  over-stimulated.  This  vascular  erethism 
especially  involves  the  gray  substance,  which  is  richer  in  capillaries  than 
the  white  matter;  for  the  same  reason,  also,  the  gray  matter  receives,  in 
cases  of  poisoning,  a  comparatively  much  larger  amount  of  the  toxic 
principle.  The  intense  irritation  of  the  delicate  network  of  nerve-cells 
will  produce  hypersemia,  and  the  latter,  on  account  of  the  excessive  sen- 
sibility of  these  elements,  may  itself  give  rise  to  reflex  spasms.  The 
prompt  disappearance  of  these  congestions,  before  they  have  produced 
more  marked  tissue  changes,  will  also  explain  the  fact  that  so  many 
cases  terminate  favorably.  If  the  congestive  processes  are  repeated  and 
prolonged,  they  give  rise  to  nuclear  proliferations  and  to  the  formation 
of  new-formed  connective  tissue.  In  a  certain  number  of  cases  a  neuri- 
tis ascendens  develops  at  the  site  of  the  wound,  and  is  propagated 
along  the  posterior  roots  to  the  white  and  especially  to  the  gray  sub- 
stance of  the  cord,  where  it  terminates  in  a  subacute  central  myelitis. 

The  greater  sensibility  and  more  complex  action  of  the  nerve-cells  of 
the  medulla  oblongata  explain  the  fact  that  the  functions  of  the  latter  are 
affected  earlier  than  those  of  the  cord  itself.  A  lesion  of  the  nucleus  of 
the  facial  nerve  and  of  the  motor  nucleus  of  the  trigeminus,  situated  in 
the  upper  half  of  the  medulla  oblongata,  causes  the  tonic  spasms  of  the 
jaw  and  face  with  which  the  disease  begins.  The  lesions  then  extend  to 
the  lower  portion  of  the  medulla,  which  contains  the  nuclei  of  the  hypo- 
glossal, pneumogastric,  glosso-pharyngeal  and  spinal  accessory  nerves,  and 
cause  disorders  of  speech,  respiration,  deglutition,  and  phonation.  The 
morbid  process  may  also  involve  the  point  of  decussation  of  the  motor 
fibres  of  the  limbs,  and  a  large  number  of  the  vascular  nerves,  whose  cen- 
tres are  contained  in  the  medulla,  as  well  as  the  different  masses  of  gray 
substance,  with  the  prolongations  and  communications  which  they  send 
into  the  cord.  The  participation  of  the  gray  substance  of  the  cord  ex- 
plains the  fact  that  both  halves  of  the  body  are  almost  always  affected 
simultaneously  with  tetanic  spasms,  and  that  unilateral  tetanus  (pleuros- 
thotonos)  is  so  rarely  observed.  When  this  condition  of  exaggerated 
excitability  of  the  motor  functions  of  the  spinal  system  is  prolonged  and 
aggravated,  it  will  result  in  a  paralysis  which  involves  the  medulla  ob- 
longata and  is  most  frequently  the  cause  of  death. 

Numerous  observations  controvert  the  opinion  that  local  irritation  of 
the  nerves  is  the  only  cause  of  tetanus.     Thus.,  after  considerable  lesions 


96  CLINICAL    TREATISE    OlST 

of  the  nerves  of  the  upper  or  lower  limbs,  I  have  seen  anaesthesia  develop, 
with  atrophy  and  paralysis,  but  without  the  slightest  manifestation  of 
tetanic  symptoms.  Remak  has  observed  quite  a  number  of  cases  of  trau- 
matic neuritis  nodosa  without  the  appearance  of  reflex  spasms,  much  less 
of  trismus  or  tetanus.  Froriep  mentions  a  case  of  inflammation  and  swell- 
ing of  the  sciatic  nerve  which  could  be  traced  to  the  spinal  cord,  but  was 
unattended  by  any  tetanic  symptoms. 

Velpeau,  Betoli,  Thompson,  Spencer  Wells,  Roser,  and  Herberg  have 
advanced  the  opinion  that  tetanus  is  a  z^^motic  disease,  due  to  a  virus  or 
miasm  sui  generis.  These  authors  refer  to  the  great  analogy  between 
tetanus  and  hydrophobia,  and  to  the  fact  that  tetanus  frequently  appears 
epidemically  and  endemically.  They  believe  that  the  surface  of  the 
wound,  whose  secretion  is  perverted,  produces  a  toxic  substance,  the 
absorption  of  which  gives  rise  to  a  disease  of  the  blood.  To  these  argu- 
ments we  may  reply  that,  in  the  first  place,  the  advocates  of  the  "fer- 
ment "  theory  have  failed  to  substantiate  their  opinions  by  analysis  of  the 
blood  or  by  practising  inoculation  with  the  fluids  secreted  b}^  the  wound, 
or  with  the  muscular  fluid  or  urine  of  patients  suffering  from  tetanus.  On 
the  other  hand,  this  theory  does  not  explain  those  cases  in  which  section 
of  a  diseased  nerve,  the  removal  of  a  foreign  body  or  of  a  ligature,  or  the 
reduction  of  fractures  attended  with  considerable  displacement  (Langen- 
beck)  have  caused  the  prompt  subsidence  of  the  symptoms  of  tetanus. 
In  such  cases  we  cannot  regard  the  blood  as  the  pathogenic  factor  of  the 
disease;  it  is  more  natural  to  consider  the  local  lesions  of  the  nerves  as 
the  primary  cause  of  the  affection.  According  to  the  investigations  of 
Funke  and  Ranke,  the  normal  alkaline  reaction  of  the  nervous  tissues 
becomes  acid  in  tetanus.  Heidenhain  has  also  observed  this  acidity  of 
the  central  nervous  system,  but  it  has  not  hitherto  been  demonstrated 
with  regard  to  the  peripheral  nerves 


Diagnosis  and  Prognosis. 

Upon  examining  the  medical  literature  of  the  subject,  it  will  become 
evident  that  many  cases  have  been  reported  as  tetanus  which  were 
merely  varieties  of  tonic  spasms  affecting  the  trunk  and  limbs.  In  all 
these  cases  the  characteristic  sign  of  morbid  increase  of  reflex  action  has 
been  entirely  lost  sight  of.  The  diseases  which  are  most  frequently  mis- 
taken for  tetanus  are  spinal  meningitis,  catalepsy,  hysteria,  hydrophobia, 
and  spasm  of  the  muscles  of  mastication. 

In  spinal  meningitis,  tonic  spasms  occur  in  the  neck,  back,  and  limbs, 
and  are  attended  with  febrile  symptoms.  But  they  are  distinguished  from 
true  tetanic  spasms  by  the  absence  of  the  enormous  increase  of  reflex  ex- 
citability, and  of  the  periodical  remissions,  and  by  the  contractures,  the 
muscular  atrophy,  and  the  paralyses  which  persist  after  the  acute  stage 
of  the  disease  has  subsided.  (For  further  details,  vide  Vol.  I.,  p.  188.)  The 
tonic  spasms  sometimes  observed  in  hysteria  are  characterized  by  their 
short  duration,  their  admixture  with  various  other  hysterical  phenomena, 
and  by  the  absence  of  abnormal  reflex  excitability.  In  cataleptic  rigidity 
(especially  in  the  catochus  of  the  ancients)  loss  of  consciousness  is  observed, 
with  suppression  of  reflex  motion,  abolition  of  the  functions  of  the  special 
senses  and  of  the  sensibility  to  pain;  finally,  we  almost  always  discover,  in 
the  previous  history,  some  indications  of  hysteria,  of  chorea  magna,  or  of 
insanity.    In  epilepsy  and  eclampsia  the  tetanic  stiffness  is  temporary;  the 


I 


DISEASES    OF   THE    NERVOUS    SYSTEM.  97 

nature  of  the  convulsions,  their  sudden  appearance,  the  characteristic  cry 
wliich  precedes  them,  the  loss  of  consciousness,  the  abolition  of  the  func- 
tions of  special  sense,  the  prompt  termination  of  the  attack,  and  the  con- 
dition of  the  urine  in  the  eclampsia  of  pregnant  women,  afford  us  sulhcient 
data  for  forming  a  diagnosis. 

Hydrophobia  is  also  characterized  by  an  exaggeration  of  the  reflex 
acts,  by  tetanic  symptoms,  and  by  spasms  of  respiration  and  deglutition. 
But  there  are  numerous  other  signs  which  enable  us  to  exclude  tetanus, 
such  as  the  much  slower  development  of  hydrophobia  after  the  receipt  of 
the  wound,  the  excessive  sensibility  of  the  patients  to  the  slightest  cur- 
rent of  air,  their  dislike  of  water  or  shining  objects,  the  sight  or  contact 
of  which  also  produces  terrible  spasms,  the  unusual  precipitation  which 
they  evince  in  their  movements,  and  often,  also,  in  their  conversation,  and 
the  attacks  of  loss  of  consciousness  with  furious  delirium  which  they 
sometimes  present. 

The  tonic  spasm  in  the  distribution  of  the  motor  portion  of  the  trigem- 
inus (facial  spasm  of  the  masticators,  Romberg)  is  observed  in  cerebral 
softening,  inflammation  of  the  brain  and  its  meninges^  or  in  consequence 
of  irritation  of  the  sensory  nerves.  In  the  first  case  its  real  nature  can 
be  determined  by  the  remaining  symptoms;  when  it  is  of  peripheral 
origin,  by  the  integrity  of  the  function  of  deglutition,  the  freedom  of  the 
other  parts  of  the  muscular  system  from  spasm  and  the  absence  of  con- 
vulsive paroxysms.  Finally,  the  tetanic  symptoms  which  sometimes  de- 
velop in  the  course  of  typhoid  fever,  the  acute  exanthemata,  pyj^mia,  and 
intermittent  fever  (in  tropical  regions)  are  readily  recognized  by  their 
irregular  development  and  termination,  and  especially  by  the  eiisemble 
of  symptoms  peculiar  to  each  of  these  diseases. 

We  possess  no  definite  signs  which  will  permit  las  to  form  a  positive 
conclusion  with  regard  to  the  termination  of  each  individual  case.  Ex- 
perience has  shown  that  recovery  is  possible,  even  after  an  exceptional 
violence  of  the  symptoms.  On  the  other  hand,  treacherous  remissions 
occur,  which  may  be  followed  by  fresh  attacks,  or  during  which  the  patients 
may  die  of  exhaustion.  We  may  state,  in  general  terms,  that  a  favorable 
termination  ma}^  be  looked  for  when  the  patient  has  previously  enjoyed 
good  health;  when  he  is  younger  than  ten  years  or  older  than  thirty  years 
of  age;  when  the  wound  is  simple  and  recent;  when  the  disturbances  of 
circulation,  respiration,  and  nutrition  are  not  very  severe  or  do  not  ap- 
pear very  early;  when  the  skin,  which  is  at  first  dry  and  cold,  recovers  its 
warmth  and  moisture;  and,  finally,  when  the  temperature  of  the  body  re- 
turns to  the  normal. 

Treatment. 

If  we  consider  the  large  number  of  successful  results  obtained  by  the 
most  varied  remedies,  and,  on  the  other  hand,  the  equally  large  number 
of  fatal  cases,  despite  all  the  measures  which  may  have  been  employed, 
we  will  become  convinced  that  we  possess  no  specific  remedy  for  tetanus, 
and  that,  in  each  case,  the  ol)ject  of  medical  intervention  is  to  diminish 
the  consequences  of  the  local  lesion,  to  relieve,  at  least  in  part,  the  dis- 
orders of  the  nervous  system,  and  to  maintain  the  strength  of  the  patient 
until  the  disease  has  run  its  course. 

Let  us  discuss,  in  the  first  place,  the  various  measures  which  consti- 
tute the  external  treatment.  The  neurotomies,  which  have  been  practised 
by  some  authors,  often  prove  ineffectual,  because  we  cannot  positively 
Vol.  II.— 7 


9'8  CLINICAL   TREATISE    ON 

determine  the  location  of  the  primarily  injured  nerve,  and  because  the 
nerve-centres  are  always  affected  unless  the  section  has  been  performed  at 
an  early  period.  Amputation  is  inadvisable,  unless  the  operation  has  been 
rendered  necessary  for  other  reasons. 

Venesection  has  few  adherents,  but,  when  cautiously  employed,  it  may 
be  useful  in  certain  cases  which  are  accompanied  by  dangerous  hyperas- 
mia.  We  may  also  derive  benefit,  at  times,  from  leeching,  wet-cups,  and 
moxae  along  the  vertebral  column.  Applications  of  ice  to  the  spine  have 
been  recommended  by  Todd,  and  especially  by  Carpenter  (the  latter  cured 
sixteen  cases  out  of  seventeen  by  this  plan  of  treatment).  Warm  baths 
of  several  hours'  duration  have  a  beneficial  effect.  Moist  packs,  followed 
by  cool  half-baths,  are  extremely  useful,  according  to  Ebert  and  Stein, 
in  combating  the  reflex  excitability  and  the  tetanic  paroxysms.  Finally, 
we  may  resort  to  the  use  of  irritating  enemata  (turpentine);  narcotic 
salves  and  chloroform  liniment  are  used  to  relieve  local  pains. 

Among  the  ana?sthetic  agents,  chloroform  and  ether  are  most  fre- 
quently employed.  Chloroform  diminishes  the  severity  of  the  spasms, 
but  only  during  the  continuance  of  the  anaesthesia,  and  the  tetanic  symp- 
toms reappear  soon  after  the  termination  of  the  latter.  According  to 
Hobart,  no  permanent  benefit  is  obtained,  even  though  the  anaesthesia  is 
continued  for  several  days.  In  one  case  this  plan  of  treatment  resulted  in 
severe  congestion  of  the  bronchi,  which  were  found  to  contain  a  large  accu- 
mulation of  mucus.  Dick,  Ord,  and  others  have  administered  chloroform 
internally  in  combination  with  other  sedative  agents.  Lately  good  results 
have  been  obtained  from  increasing  doses  of  hydrate  of  chloral. 

The  narcotics  have  been  highly  esteemed  from  the  earliest  periods. 
Aconite,  recommended  by  Paget  and  Campbell,  and,  more  recently,  by 
Wunderlich  (tincture  of  aconite,  five  to  ten  drops,  three  or  four  times  a  day, 
in  increasing  doses),  lessens  the  frequency  of  the  pulse  and  retards  the 
convulsions. 

Belladonna,  according  to  Dupuy  and  Fournier,  diminishes  the  rigidity 
of  the  muscles,  but  is  more  efficacious  when  given  in  the  form  of  hypo- 
dermic injections  of  atropine  than  when  administered  internally.  Ex- 
tract of  cannabis  indica  is  given  in  doses  of  0.20-0.30  every  hour.  Ac- 
cording to  experiments  made  upon  frogs,  nicotine  has  the  power  of  neu- 
tralizing the  tetanizing  action  of  strychnine.  Harrison  and  Haughton  have 
given  it  in  doses  of  two  to  four  milligrammes  (dissolved  in  water  and  alco- 
hol) every  two  or  three  hours;  it  diminishes  the  action  of  the  heart  and 
the  muscular  spasms,  and  stimulates  the  functions  of  the  skin.  This  sub- 
stance is  an  active  cardiac  poison,  and  its  administration  is  sometimes 
attended  with  danger  ;  in  the  majority  of  cases  it  is  preferable  to  admin- 
ister strong  enemata  of  tobacco  in  its  stead.  Opium  is  one  of  the  most 
frequently  employed  and  most  useful  remedies  in  this  affection.  It  is 
given  in  large  doses,  from  0.05-0.10  hourly,  until  the  appearance  of 
symptoms  of  relaxation.  In  periodical  tetanus  it  is  combined  with  qui- 
nine, and  the  patients  sometimes  tolerate  enormous  doses.  Subcutaneous 
injections  of  morphine  have  also  been  employed,  especially  in  trismus. 
The  good  results  which  certain  authors  attribute  to  this  plan  of  medica- 
tion have  not  been  obtained  in  many  of  the  cases  observed  in  the  Vienna 
General  Hospital. 

Other  remedies  have  been  recently  employed,  such  as  bromide  of  potas- 
sium, curare,  extract  of  calabar-bean,  and  electricity.  Bromide  of  potas- 
sium, to  the  depressing  action  of  which  upon  reflex  action  we  have  so  fre- 
quently alluded,  has  been  particularly  recommended  by  Thompson.    It  must 


DISEASES    OF   THE    NERVOUS    SYSTEM.  99 

be  given  in  large  doses  (sixteen  to  eighteen  grammes  daily).  The  experi- 
ments of  CI.  Bernard  have  proved  that  curare  abolishes  the  irritability  of  the 
cord  and  of  the  motor  nerve-trunks,  but  has  no  effect  upon  the  excitability 
of  the  muscles.  The  first  experiments  upon  man  were  made  in  1859,  by  Vel- 
la,  vrho  employed  it  in  trismus  in  the  form  of  compresses  soaked  with  curare 
and  applied  to  the  wound.  Shortly  afterwards,  Demme  and  Gherini  pub- 
lished cases  of  tetanus  cured  by  subcutaneous  or  intra-muscular  injections 
of  curare.  The  dose  to  be  used  as  injection  is  0.01-0.07;  at  the  end  of 
a  few  minutes  the  spasms  diminish  and  the  pulse  becomes  less  rapid; 
the  injection  may  be  renewed  at  the  end  of  three  or  four  hours,  after  the 
effect  of  the  former  one  has  passed  away.  Among  ten  cases  of  tetanus 
from  gunshot  wounds,  which  were  treated  with  curare  by  Busch,  five 
cases  recovered.  The  extract  of  calabar-bean  is  also  preferably  employed 
in  the  form  of  hypodermic  injections,  0.02-0.07  every  two  or  three  hours; 
it  is  advisable  to  add  some  carbonate  of  potash  to  the  solution,  in  order 
to  diminish  the  pain  which  the  injection  causes  and  to  prevent  the  for- 
mation of  abscesses.  Up  to  the  year  1868  six  cases  of  recovery  under 
this  plan  of  treatment  were  reported. 

In  1838  Matteucci  published  a  case  of  traumatic  tetanus,  in  which  he 
had  succeeded  in  diminishing  for  some  time  the  violence  of  the  par- 
oxysms by  means  of  the  constant  galvanic  current  (Volta's  pile  of  forty 
elements).  In  a  case  published  by  M'Dowall  (Lancet,  1861),  the  dysp- 
noea was  diminished  and  the  spasms  suspended  for  two  hours  by  a  single 
application  of  an  electro-magnetic  apparatus.  The  physician  having  left, 
the  electrization  was  suspended,  and  the  patient  died.  Nobili,  and,  more 
recently,  Ranke,  having  stated  that  the  muscles  of  tetanized  frogs  relax 
under  the  influence  of  the  constant  current,  E.  Mendel  employed  the  gal- 
vanic treatment  with  good  results  in  several  cases  of  tetanus  in  man  (Ber. 
Klin.  Wschr.,  38,  1868).  He  placed  the  negative  pole  upon  the  cervical 
vertebrje,  the  positive  pole  upon  one  of  the  lower  or  upper  limbs,  and  al- 
lowed the  current  to  pass  from  ten  to  fifteen  minutes.  The  relaxation 
which  was  thus  obtained  remained  persistent  after  several  seances,  and 
the  patient  made  an  excellent  recovery. 


I 


100  CLINICAL   TREATISE   ON" 


CHAPTER  XXXII. 

HYDROPHOBIA. 

At  the  commencement  of  this  century  the  specific  nature  of  hydro- 
phobia was  often  called  in  question,  and  the  disease  was  either  regarded 
as  an  epidemic  catarrh  of  the  pharynx,  with  secondary  affection  of  the 
brain,  as  traumatic  tetanus,  or  as  a  psychical  neurosis.  At  the  present 
day  all  these  theories  are  abandoned,  and  h^'drophobia  is  now  considered 
to  be  a  cerebro-spinal  neurosis  of  a  contagious  nature. 

When  individuals  are  bitten  by  animals,  such  as  dogs,  cats,  wolves, 
and  foxes  which  are  mad  or  suspected  of  madness,  and  the  necessary 
measures  are  not  immediately  adopted,  the  patients  usually  become  af- 
fected with  that  peculiar  and  terrible  toxic  neurosis  known  as  hydropho- 
bia. The  period  of  incubation  varies  considerably  in  duration.  Accord- 
ing to  Hamilton's  and  Thamhayn's  statistics,  it  generally  occupies  from 
eighteen  to  fifty-nine  days.  The  earliest  outbreak  of  the  disease  occurs 
during  the  first  week;  sometimes  the  period  of  incubation  may  last  several 
months,  and  there  are  a  few  examples  on  record  (though  they  must  be 
looked  upon  with  suspicion)  in  which  it  lasted  several  years. 

The  following  prodromata  of  the  disease  are  often  observed:  chills, 
malaise,  distaste  for  fluids,  embarrassment  of  deglutition  and  respiration, 
painful  sensations  in  the  neighborhood  of  the  bite,  or  pains  radiating 
from  this  locality  along  the  nerve-trunks;  finally,  muscular  contractions  in 
the  limbs  and  psychical  disorders.  The  duration  of  this  stage  varies  from 
one  to  four  days. 

The  onset  of  the  disease  may  develop  from  the  increase  of  the  prodro- 
mata mentioned  above,  or  it  may  begin  suddenly.  The  primary  difficulty 
in  deglutition  may  be  followed  by  an  intense  spasm  of  the  pharynx,  and 
respiration,  which  was  previously  labored,  is  rendered  still  more  so  by 
spasm  of  the  respiratory  muscles;  or  perhaps  the  patient  is  suddenly 
seized,  while  about  to  drink,  with  a  terrible  spasmodic  paroxysm.  In  less 
severe  cases  the  patients  are  able  to  drink,  but  the}'^  carry  the  glass  very 
rapidly  to  the  mouth,  and  swallow  precipitately.  Upon  closing  the  eyes, 
or  upon  handing  them  the  liquids  in  opaque  vessels,  the  disturbances  of 
deglutition  are  sometimes  overcome  more  readily. 

This  feeling  of  abhorrence  of  water  may  increase  to  «uch  a  degree  that 
a  paroxysm  will  develop  from  the  mere  sight  of  water,  from  contact  with 
it,  from  hearing  the  noise  made  by  pouring  it  from  one  vessel  to  another, 
or,  perhaps,  from  merely  hearing  compresses  wrung  out.  In  severe  cases 
there  is  an  absolute  impossibility  of  swallowing  liquids  (deglutition  of 
solid  substances  is  almost  always  difficult,  but  is  preserved).  If  the  pa- 
tient attempts  to  drink,  or  if  the  skin  is  moistened  with  water,  spasms 
develop,  which  are  attended  with  asphyxia,  convulsions  of  the  pharynx, 
face,  and  -entire  body,  and  a  condition  of  intense  excitement.  A  piece  of 
ice  placed  upon  the  tongue  will  produce  a  paroxysm;  this  will  also  be 
provoked  by  swallowing  saliva,  and  the  patients  therefore  expectorate 


DISEASES    OF   THE    NERVOUS    SYSTEM.  101 

considerably.  It  is  a  remarkable  fact  (according  to  Thamhayn  and  Yol- 
tolini)  that  the  patients  generally  tolerate  warm  baths  quite  well  at  this 
stage  of  the  disease. 

The  irritability  of  the  senses  is  manifested  by  the  extreme  sensibility 
to  the  slightest  currents  of  air,  to  light  and  to  shining  objects.  Under 
the  inßuence  of  these  causes,  the  patients  make  active  movements  of  in- 
spiration, carry  the  head  backwards,  or  are  even  affected  with  general 
convulsions.  They  manifest  extreme  precipitation  in  all  their  movements, 
and  sometimes  display  an  astonishing  loquacity.  In  children,  hydropho- 
bia usually  assumes  the  characteristics  of  some  form  of  insanity,  the  hy- 
pergesthetic  symptoms  predominating,  but  without  any  especial  tetanic 
phenomena. 

The  face  is  pale  or  very  livid,  and  bears  an  expression  of  restlessness 
or  sadness.  The  eyes  are  usually  hxed  and  glassy,  more  rarely  they  roll 
in  the  orbits;  the  pupils  are  dilated,  but  sometimes  contract  temporarily 
under  the  influence  of  light. 

During  the  course  of  the  disease  convulsive  movements  are  observed 
in  the  muscles  of  the  face,  jaw,  neck,  and  trunk,  and  tetanic  spasms  may 
even  occur  in  the  limbs.  The  patients  complain  of  painful  sensations  in 
the  head,  neck,  back,  epigastrium,  or  in  the  limb  which  has  been  bitten. 

Consciousness  is  often  preserved  until  death;  in  certain  cases  it  is 
lost  from  the  third  or  fifth  day,  and  the  patient  presents  illusions  of  the 
senses,  delirium,  exaltation,  or  even  attacks  of  mania  and  insanity,  with 
or  without  attempts  at  biting  the  attendants.  Insomnia  occurs  in  most 
cases,  but  we  may  also  observe  the  various  phases  of  half-sleep. 

The  respiration  often  presents  no  peculiaritj'  in  the  interval  of  the  at- 
tacks; during  the  paroxysms  it  is  more  or  less  labored,  panting,  and  irre- 
gular, and  at  times  the  dyspnoea  becomes  excessive. 

The  respiratory  disorders  may  be  isochronous  with  the  pharyngeal  and 
laryngeal  spasms,  or  may  precede  them.  As  a  rule,  the  patients  avoid 
deep  inspirations,  because  they  are  apt  to  produce  convulsions.  The 
pulse  is  frequent  and  small  from  the  beginning,  and  these  qualities  in- 
crease in  intensity  towards  the  termination  of  the  disease. 

The  digestive  apparatus  is  usually  but  slightly  affected.  Despite  the 
great  increase  of  general  sensibility,  the  nerves  of  the  stomach  react 
very  feebly  to  the  action  of  tartar  emetic,  and,  according  to  Schuh,  it 
may  often  be  given  in  large  doses  without  producing  any  effect.  The 
appetite  is  usually  lost.  The  patient  almost  always  suffers  from  excessive 
thirst,  together  with  a  sensation  of  burning  in  the  throat;  and  the  saliva, 
which  is  expectorated  with  frequency,  is  frothy,  mucous,  and  adherent. 
The  pustules,  described  by  Marochetti  under  the  term  "  lysses,"  are  found, 
in  the  first  few  days  of  the  period  of  incubation,  upon  the  sides  of  the 
fra^num  linguae.  In  a  case  published  recently  by  Crequy,  the  urine  con- 
tained an  abundance  of  sugar. 

Towards  the  termination  of  the  disease,  which  almost  always  proves 
fatal,  the  symptoms  become  more  severe.  The  patients  are  extremely 
agitated,  and  are  continually  expectorating  in  all  directions  ;  bluish  spots 
appear  upon  the  sweat-covered  skin.  Vomiting  very  frequently  occurs, 
and  the  vomited  matters  are  frotliy,  sanguinolent,  and  look  like  coffee- 
grounds;  the  pulse  is  extremely  weak.  The  patients  die  suddenly  in 
convulsions,  or  in  the  midst  of  symptoms  of  jactitation,  attended  with 
loss  of  consciousness,  A  few  hours  before  death  a  deceptive  calm  is 
sometimes  observed,  during  which  the  patients  may  even  recover  the 
power  of  drinking. 


102  CLINICAL   TREATISE    ON 


Pathological  Anatomy  and  Histology. 

Among  the  autopsies  collected  by  Thamhayn,  we  find  the  following 
lesions  mentioned  on  several  occasions:  abundance  of  blood  in  the  brain, 
dark  coloration  of  the  cortical  substance,  foyers  of  softening  in  the  optic 
thalamus  or  corpus  striatum,  extreme  vascularization  of  the  medulla  ob- 
longata, congestion  of  the  spinal  meninges,  congestion  of  the  cord  with 
partial  softening ;  at  times  the  sympathetic  and  phrenic  nerves  and 
the  cerebral  branches  of  the  pneumogastric  nerve  have  been  found  in- 
jected. In  some  cases  the  peripheral  nerves  of  the  arm  which  had  been 
bitten  presented  a  reddish  coloration.  The  respiratory  apparatus  was 
almost  always  extremely  hyper^emic.  The  papillas  of  the  tongue  and 
pharynx  sometimes  projected  to  an  extreme  degree,  and  now  and  then 
small  bull;«  were  found  upon  the  lower  surface  of  the  tongue. 

In  1869  Meynert  made  some  extremely  interesting  histological  in- 
vestigations upon  the  brain  and  spinal  cord  of  two  patients  (a  boy  and  a 
gii'l)  who  had  died  of  hydrophobia  in  Oppolzer's  service.  In  these  pa- 
tients the  hydrophobia  had  manifested  itself  as  a  form  of  psychosis,  with 
predominance  of  symptoms  of  hyperaesthesia,  temporary  spasms  of  the 
respiratory  muscles,  especially  when  about  to  drink,  but  without  any 
tetanic  symptoms. 

In  the  first  case  the  cord  presented  the  following  appearances:  the 
reticulum  had  preserved  its  delicacy;  the  vessels  were  filled  with  blood 
(the  latter  was  coagulated,  and  looked  like  small  colloid  masses),  and 
their  walls  partially  affected  by  amyloid  degeneration;  in  some  of  them 
the  tunica  adventitia  presented  nuclear  proliferations.  Some  of  the 
nerve-fibres  were  surrounded  by  a  considerably  swollen  medullary  sub- 
stance, which  resisted  mechanical  action  (traction);  others  presented  all 
the  stages  intermediate  between  this  and  colloid  degeneration  and  de- 
struction of  the  fibres;  in  certain  places  the  axis  cylinders  had  disap- 
peared. These  lesions  were  somewhat  more  marked  in  the  lumbar  than 
in  the  cervical  region. 

In  the  second  case  the  reticulum  of  the  posterior  spinal  columns  was 
hypertrophied  from  excessive  enlargement  of  the  stellate  neuroglia-cells; 
in  the  antero-lateral  column  the  reticulum  was  transformed  into  small, 
finely  granular  fibrilhe,  the  vessels  were  filled  with  blood,  and  their  walls 
Avere  partially  affected  with  amyloid  degeneration.  The  cortex  and 
medullary  substance  of  the  brain  presented  a  large  number  of  irregular 
vacuoles,  which  did  not  always  contain  anatomical  elements,  and  which 
pressed  the  bundles  of  white  fibres  aside  in  a  curved  form.  Traces  of 
colloid  substance  were  found  in  the  perivascular  spaces  and  in  some  of 
the  vacuoles  scattered  through  the  nervous  tissue.  A  large  number  of 
the  ganglion-cells  of  the  cerebral  cortex  presented  the  appearances  of 
molecular  destruction,  while  others  were  very  much  swollen  and  sclerosed. 
According  to  Meynert,  these  appearances  were  due  to  an  oedematous 
process,  caused  by  an  exudation  from  the  markedly  congested  vessels. 
He  thinks  that  the  exudation  was  beginning  to  diffuse  itself  into  the 
nerve-tissues  (because  no  obliteration  of  the  perivascular  spaces  was 
noticeable).  On  the  other  hand,  the  exudation  presents  the  appearances 
of  a  very  thin  colloid  matter  which  has  assumed,  from  an  exchange  with 
the  protein  compounds  scattered  throughout  the  tissues,  their  optical 
characteristics. 

In  a  more  recent  case,  reported  by  Hammond,  microscopical  examina- 


DISEASES    OF   THE    NERVOUS    SYSTEM.  103 

tion  of  the  cerebral  cortex  showed  enlargement  and  thickening  of  the 
vessels;  the  outer,  and,  to  a  less  degree,  the  second  layer  of  nerve-cells 
were  infiltrated  with  fatty  granulations  and  amyloid  corpuscles;  the  cere- 
bral ganglia  were  normal.  In  the  nuclei  of  the  pneumogastric  and  hypo- 
glossal nerves  the  vessels  were  also  enlarged,  and  the  ganglion-cells  were 
granular  and  markedly  diminished  in  number  and  size;  the  roots  of  the 
pneumogastric,  spinal  accessory,  and  hypoglossal  nerves  were  involved  in 
the  same  degeneration.  Analogous  changes  were  present  in  the  gray 
substance  of  the  cord;  the  neuroglia-cells  in  the  white  substance  were 
undergoing  nuclear  proliferation.  Clifford  Albutt  made  a  similar  series 
of  observations  in  two  cases  of  hydrophobia. 

"We  may,  finally,  mention  the  results  obtained  by  Prof.  Ragsky  (Oester. 
Jahrb.,  Aug.,  1843)  from  a  chemical  analysis  of  the  blood.  He  found 
that  the  blood  acquired  a  neutral  reaction,  whereas  in  the  normal  con- 
dition it  was  feebly  alkaline;  it  contained  73.59  parts  per  100  of  water, 
instead  of  the  normal  amount  (80  per  100) ;  and  2.9  parts  of  solid  matters, 
instead  of  4.42.  1,000  parts  contained  4.8  of  fibrin,  133  of  hemato-globu- 
line,  80.2  of  albumen,  12.4  of  extractive  matters  and  salts,  and  796.6  of 
water.  It  is  very  desirable  that  new  analyses  of  a  similar  character  should 
be  undertaken. 

Nature  of  Hydrophobia. 

The  pathognomonic  symptoms,  as  well  as  the  anatomical  lesions  found 
in  the  brain  and  cord,  prove  that  hydrophobia  in  man  is  due  to  a  toxic 
change  in  the  nerve-centres.  The  rabietic  poison  which  is  inoculated  by 
the  bite  acts,  to  all  appearances,  like  a  fixed  ferment.  The  part  played  by 
the  blood,  as  the  agent  for  the  transportation  of  the  morbid  principle,  was 
demonstrated  by  the  experiments  of  Hertwig  (Hufeland's  Journ.,  1828, 
p.  168),  who  found  that  the  virulent  action  was  transmitted  by  the  fluid 
extracted  from  the  salivary  canals  and  by  the  venous  and  arterial  blood. 
Magendie  and  Breschet  successfully  inoculated  two  dogs  with  the  saliva 
of  a  man  who  had  died  of  hydrophobia.  The  lesions  indicative  of  oedema, 
observed  by  Meynert,  lead  us  to  suspect  a  vascular  transudation  into  the 
adjacent  tissue,  and  this  process  is  rendered  easy  by  the  changes  found 
in  the  walls  of  the  vessels. 

We  may  apply  to  rabietic  poisoning  the  remark  which  we  made  in  the 
preceding  chapter,  viz.,  that  the  medulla  oblongata  undergoes  more  pro- 
found changes  than  the  cord,  and  that  the  centres  of  respiration  and 
deglutition  are  the  first  to  react  to  these  lesions.  The  phenomena  which 
appear  soon  afterwards,  such  as  hyperaesthesia,  painful  sensations,  con- 
vulsive and  tetanic  symptoms,  denote  the  invasion  of  the  spinal  cord  by 
the  toxic  action,  and  the  psychical  disorders  correspond  to  the  implication 
of  the  cerebral  cortex.  These  symptoms  are  due  to  the  tissue  changes 
which  were  first  discovered  by  Meynert  in  the  nerve-centres.  The  pro- 
dromata,  which  precede  (for  one  to  four  days)  the  invasion  of  the  disease, 
are  evidently  the  first  manifestations  of  the  toxic  irritation.  The  duration 
of  the  period  of  incubation  depends  upon  the  activity  of  the  poison  and 
upon  the  greater  or  less  length  of  time  in  which  the  textural  changes 
develop. 

The  receptivity  of  the  organism  is  very  variable,  as  Hertwig  has  ex- 
perimentally demonstrated  upon  animals.  Of  fifty-nine  animals  which 
were  inoculated,  only  fourteen  were  infected;  in  some  a  single  inocula- 
tion sufficed  to   produce  infection,  in   others  three  or  four  inoculations 


104  CLINICAL    TREATISE    ON 

became  necessary.  It  has  been  shown  in  man  that  certain  accidental 
causes  (emotions,  excesses,  exposure),  which  diminish  the  force  of  re- 
sistance of  the  nervous  system,  may  also  favor  the  onset  of  the  disease. 


Diagnosis  and  Prognosis. 

—  The  diagnosis  of  hydrophobia  lyssodes  is  rendered  positive  hj  the 
fact  that  the  patient  has  been  previously  bitten  by  a  rabid  animal,  and 
by  the  progressive  aggravation  of  the  spasms  of  respiration  and  deglutition. 
The  hydrophobic  symptoms,  which  are  sometimes  observed  under  the  in- 
fluence of  other  diseases,  are  readily  distinguished  with  a  little  attention. 

Imaginary  hydrophobia  is  merely  the  result  of  excessive  fear;  it  is 
unattended  by  any  exaggeration  of  reflex  action,  and  moral  treatment  is 
alone  required.  The  development  of  spontaneous  hydrophobia  has  not 
been  hitherto  demonstrated  in  man. 

In  hysterical  hydrophobia,  spasms  of  the  pharynx  and  glottis  also  occur, 
but  these  attacks  are  usually  of  short  duration,  and  they  are  accompanied 
by  other  hysterical  symptoms  and  by  characteristic  disorders  of  sensation 
and  motion.  Finally,  symptomatic  hydrophobia,  which  is  observed  as  a 
rare  complication  of  diseases  of  the  pharynx  and  larynx,  of  cerebral  affec- 
tions, of  typhoid  fever,  and  of  pernicious  fevers,  is  recognized  without 
difBculty  by  the  other  symptoms  of  the  disease. 

The  ^>ro</;i06v's  is  generally  extremely  unfavorable.  Of  two  hundred 
and  sixteen  cases  collected  by  Thamhayn,  there  were  only  six  observations 
by  Smith  (four  of  which  occurred  after  bites  of  dogs  which  were  undoubt- 
edly rabid)  which  terminated  in  recovery,  or  a  proportion  of  one  to 
thirty-six.  The  majority  of  the  patients  die  upon  the  fourth  or  fifth  day 
from  the  appearance  of  the  first  paroxysm.  According  to  the  medical 
laws  of  Austria,  every  individual,  suspected  of  hydrophobia,  must  remain 
forty-two  days  under  medical  surveillance.  At  the  expiration  of  this 
period,  if  no  general  symptoms  have  appeared,  it  is  very  probable  that 
the  disease  will  not  develop. 

The  prognosis  is  more  favorable  if  the  virus  has  been  destroyed  by 
immediate  cauterization  of  the  wound,  or  within  twenty-four  to  forty- 
eight  hours.  According  to  the  recent  observations  of  Renault,  the  absorp- 
tion of  the  virus  from  the  wound  occurs  with  such  rapidity  that  very 
little  is  to  be  hoped  for  even  from  immediate  cauterization.  Nevertheless, 
in  a  large  number  of  cases  energetic  cauterization,  performed  within 
twenty-four  or  forty-eight  hours,  has  prevented  the  development  of  the 
disease.  Some  cases  have  been  reported  in  which  the  affection  developed 
with  a  slower  course  than  usual,  despite  cauterization  performed  upon  the 
day  after  the  bite;  other  cases  have  escaped,  in  which  the  cauterization 
was  only  performed  several  days  after  the  receipt  of  the  wound.  We 
must,  therefore,  conclude  that  the  individual  receptivity,  as  well  as  the 
energy  of  the  virus,  is  liable  to  variation. 


JVeatment. 

The  chief  importance  should  be  attached  to  the  prophylactic  treat- 
ment. The  best  measure  consists  in  cleansing  the  wound  and  cauterizing 
it  with  the  hot  iron  or  with  caustic  potash;  nitrate  of  silver  is  ineffectual. 
The  wound  should  be  kept  open  for  five  or  six  weeks  by  means  of  ung. 


DISEASES    OF   THE    NERVOUS    SYSTEM.  105 

basilic,  since  experience  has  proved  tliat  if  the  disease  does  develop,  the 
symptoms  will  be  less  severe  if  the  vpound  suppurates.  When  the  wound 
changes  its  appearance,  or  when  it  becomes  the  seat  of  unusual  sensibility, 
the  cicatrix  must  be  opened  without  delay  and  suppuration  induced. 
In  a  case  reported  by  Hooper,  which  terminated  in  recovery  (Med.  Times, 
May,  1847),  the  cicatrix  had  reopened  and  suppurated  spontaneously. 
In  addition,  care  must  be  taken  that  the  patient  is  kept  perfectly  quiet. 
When  the  patient  has  been  wounded  in  several  places,  Fuchs  has  ob- 
tained good  results  by  immediately  placing  the  patients  in  mercurial 
baths  (which  cauterize  all  the  affected  parts). 

The  efforts  which  have  been  made  for  centuries,  to  discover  an  anti- 
dote to  the  rabietic  poison,  have  proved  fruitless.  Nevertheless,  re- 
newed experiments  upon  dogs  may  not  prove  useless  with  regard  to  treat- 
ment. Injections  of  warm  water  into  the  veins,  performed  by  Magendie 
upon  dogs,  have  also  produced  in  man  a  marked  improvement  in  the 
most  threatening  symptoms,  though  only  for  a  certain  length  of  time. 
To  judge  from  the  happy  effects  of  transfusion  in  eclampsia,  this  meas- 
ure should  also  be  emplo3'ed  in  hydrophobia.  Venesection  and  amputa- 
tion of  the  bitten  part  must  be  avoided  on  account  of  their  debilitating 
and  exciting  action. 

Opium,  belladonna,  cantharidis  (internally  and  externally),  and  mer- 
curials (either  alone  or  combined  with  musk),  have  proved  as  useless  as 
the  innumerable  other  extraordinary  measures  which  have  been  em- 
ployed. Warm  baths  produce  a  certain  degree  of  calm  ;  Buisson  has 
obtained  good  effects  from  vapor- baths,  and  Gosselin  by  producing  copi- 
ous perspiration.  We  may  finally  add  that  Schivardi  caused  a  cessation 
of  the  hydrophobic  symptoms  by  employing  the  continuous  current  for 
several  days  (from  the  soles  of  the  feet  to  the  forehead) ;  his  patient  died, 
however,  from  exhaustion.  The  results  obtained  by  several  authors  in 
tetanus,  by  early  injections  of  curare,  should  encourage  us  to  employ  the 
same  remedy  in  hydrophobia.  Offenberg  (Diss.  Inaug.,  Berlin,  1875)  has 
recently  published  a  case  in  which  injections  of  0.03  of  curare  (seven 
doses  within  five  and  a  half  hours)  caused  the  complete  disappearance  of 
the  spasms  and  of  the  hydrophobic  and  photophobic  symptoms.  These 
symptoms  were  replaced  by  paralysis  of  the  limbs,  which  was  only  re- 
lieved after  a  period  of  two  months,  the  patient  still  manifesting  great 
slowness  in  his  gait  at  the  end  of  that  time. 


CLASS    VI. 


NEUROSES  ASSOCIATED   WITH    TREMOR  AND    DISORDERS    OF 

CO-ORDINATION. 


CHAPTER  XXXIII. 

TBEMOR   AND    PARALYSIS   AGITANS. 

a.   Tremor. 

Tremor  consists  of  a  series  of  intermittent  clonic  muscular  spasms,  of 
short  excursion,  which  may  be  called  into  action  by  central  action  or  by 
peripheral  irritation.  It  may  be  experimentally  produced  in  decapitated 
animals,  by  subjecting  the  cord  to  a  weak  current  furnished  by  an  in- 
duction apparatus  with  slow  interruptions  (Volkmann),  Upon  repeating 
the  same  experiment  upon  frogs  which  have  been  poisoned  by  nicotine, 
tremor  will  be  produced  throughout  the  entire  body.  It  will  not  develop 
if  curare  has  been  previously  injected  or  if  the  nervous  centres  have  been 
destroyed;  tremor  will  occur,  however,  if  the  pons  and  medulla  oblongata 
have  been  preserved  (Vulpian),  According  to  Schiff,  by  detaching  a 
motor  nerve  from  its  centre  (the  facial  or  hypoglossal,  for  example) 
movements  of  oscillation  will  occur  in  the  muscles  which  have  been  para- 
lyzed by  the  nerve  section.  These  movements  continue,  as  a  rule,  for 
two  days,  and  may  even  persist  for  weeks  or  months. 

In  man,  tremor  indicates  an  abnormal  condition  of  irritation  of  the 
nervous  centres.  This  exaggeration  of  excitability  may  have  its  seat  in 
the  brain,  as  in  psychical  excitement  (sorrow,  fright,  anguish),  when  the 
whole  body  is  affected  with  tremor;  or  it  may  be  observed,  as  the  first 
symptom  of  motor  irritation,  in  tumors,  sclerosis,  or  softening  which  in- 
volve the  cerebral  ganglia  or  adjacent  parts  (Duchek,  Leyden,  Charcot). 
It  is  evident  that  the  morbid  excitability  which  accompanies  tremor  is 
frequently  situated  in  the  spinal  cord.  Intermittent-  muscular  spasms 
may  be  produced  in  the  various  degenerations  of  the  cord  (after  trauma- 
tism or  in  progressive  muscular  atrophy)  under  the  form  of  limited  contrac- 
tions, or  of  more  extended  clonic  spasms  occupying  the  limbs  or  trunk. 
These  spasms  are  reflex  and  are  caused  by  irritation  of  the  cord,  especially 
of  the  gray  substance.  Tremor  is  not  infrequently  due  to  shortening  of 
the  antagonistic  muscles,  causing  trembling  and  jerking  movements.  In 
cases  of  intense  irritability  of  the  nerve-centres  (as  in  cerebro-spinal  scle- 
rosis and  certain  forms  of  myelitis  and  ataxia),  the  influence  of  volition 


108  CLINICAL    TREATISE    ON" 

will  suflfice  to  irritate  the  motor  nerves  and  produce  very  marked  tremor 
of  the  limbs. 

In  the  affections  to  vphich  we  have  referred  above,  the  tremor  only 
occurs  after  voluntary  motion,  ps3'chical  irritation,  or  peripheral  impulses 
(as  in  passive  movements).  In  another  series  of  cases,  however,  it  per- 
sists during  repose,  and  only  disappears  under  the  influence  of  sleep. 
In  these  instances  voluntary  impulse  may  nevertheless  serve  to  increase 
the  intensity  of  the  tremor.  The  momentary  expenditures  of  force 
usually  preserve  their  normal  vigor,  though  often  accompanied  by  ex- 
treme exhaustion.  The  various  forms  included  in  this  category  result 
from  the  action  of  toxic  substances  (alcohol,  opium,  metallic  poisons),  or 
of  severe  diseases  (typhoid  and  intermittent  fever,  pneumonia  of  drunk- 
ards). In  these  conditions  of  morbid  excitability  of  the  nervous  centres 
the  oscillations  of  the  current  of  blood  will  sufBce  to  produce  muscular 
spasms.  In  recent  forms  the  motor  and  sensorv  action  of  the  galvanic  cur- 
rent upon  the  nerves  may  be  considerably  increased,  but  it  is  diminished, 
on  the  other  hand,  in  the  older  forms.  In  sclerosis  of  the  nerve-centres, 
and  in  the  tremor  caused  by  disturbances  in  the  spinal  axis,  intense  tremor 
may  often  be  produced  by  means  of  strong  induction  currents. 

The  tremor  may  only  involve  individual  limbs  (more  frequently  the 
upper  than  the  lower)  or  merely  the  muscles  of  the  neck  or  head.  But 
in  other  cases  almost  all  the  muscles  are  affected,  including  those  of  the 
face,  lower  jaw,  and  tongue;  speech  is  then  markedly  embarrassed.  The 
tremulous  movements  are  sometimes  limited  to  the  ocular  muscles  (under 
the  form  of  nystagmus).  Tremor  mav  also,  as  we  have  indicated  above, 
appear  temporarily  under  the  influence  of  certain  sensorial  impressions, 
or  in  the  course  of  certain  diseases;  it  sometimes  constitutes  a  symptom 
which  continues  during  life.  The  modifications  with  regard  to  intensity 
generally  depend  upon  causes  to  which  we  have  referred  above. 

From  an  etiological  point  of  view,  we  may  state,  in  the  first  place, 
that  tremor  preferably  attacks  nervous  and  easily  excited  individuals. 
Delicate  children,  born  of  a  nervous  mother,  very  frequently  manifest 
the  affection  during  the  first  years  of  life.  This  is  noticeable  by  the  man- 
ner in  which  they  hold  their  spoon,  or  in  their  first  attempts  at  writing; 
it  disappears  as  the  children  grow  stronger.  The  female  sex,  more  sen- 
sitive and  more  readily  excited,  generally  presents  a  greater  predisposition 
to  tremor  than  the  male  sex.  In  the  latter,  irritation  of  the  genital  func- 
tions, and  especially  onanism,  are  the  causes  of  the  early  and  obstinate 
forms  of  the  affection. 

At  a  more  advanced  age  it  may  be  produced  by  chronic  alcoholism, 
the  opium  habit,  the  abuse  of  strong  tobacco,  the  action  of  mercurial  va- 
pors, or  of  lead  preparations  to  which  the  system  is  subjected  in  certain 
trades,  and  the  prolonged  use  of  cosmetics  or  paint  containing  mercury  or 
lead.  Severe  diseases  are  not  infrequently  followed  by  tremor  of  the 
limbs.  This  is  also  true  of  copious  haemorrhages,  hysteria,  continued  or 
repeated  depressing  moral  agencies,  and  physical  or  intellectual  efforts. 
Finally,  the  weakness  of  old  age  also  favors  the  appearance  of  tremor. 

In  the  treat)nent  of  tremor,  we  must  endeavor  to  remove  the  primary 
cause,  to  diminish  the  morbid  excitability  of  the  nerve-centres,  and  to 
suppress  certain  injurious  influences.  The  nervous  tremor  of  childhood 
and  puberty  may  be  combated  by  washing  the  entire  body  with  cold 
water  or  vinegar,  and  by  means  of  cold  affusions  to  the  back  while  the 
patient  is  in  a  lukewarm  half-bath.  In  the  anasmia  or  general  weakness 
following  severe  diseases,  we  may  employ,  in  addition  to  the  preceding 


DISEASES    OF   THE    NERVOUS    SYSTEM.  109 

measures,  ferruginous  mineral  waters,  quinine,  light  wines,  and  a  trip  to 
the  mountains. 

In  the  tremor  resulting  from  extreme  excitability  of  the  spinal  system, 
Eulenburg  (Ber.  klin.  Wschr.,  46,  187:2)  obtained  good  effects  from  the 
administration  of  arsenic. 

Starting  from  the  experiments  of  Sklarck  (Reichert  and  Du  Bois' 
Archiv.,  18G6),  who  found  that  preparations  of  arsenious  acid  produced 
paralysis  of  the  sensory  portions  of  the  cord  with  preservation  of  the 
motor  functions,  Eulenburg  at  first  gave  Fowler's  solution  internally,  but 
without  success.  The  tremor  only  disappeared  after  the  employment  of 
subcutaneous  injections  (one  part  of  Fowler's  solution  to  two  of  water; 
a  third  or  half  of  a  syringeful,  representing  0.11-0.17  of  the  mixture,  was 
at  first  given  daily,  and  then  every  two  days). 

Excellent  effects  are  often  obtained  from  the  use  of  hydrotherapeutic 
measures;  they  diminish  the  morbid  excitability  of  the  centres  and  the 
excess  of  reflex  action.  We  may  begin  with  cool  dorsal  irrigations  in  a 
half-bath  whose  temperature  is  gradually  lowered.  As  the  nervous  sys- 
tem recovers  its  tone,  these  measures  may  be  replaced  by  douches  and 
full  baths.      Sea-baths  are  also  useful  in  these  cases. 

Electrical  treatment  appears  advantageous  in  certain  forms  of  tremor. 
Ascending  or  descending  stabile  galvanic  currents  maybe  passed  through 
the  vertebral  column,  and  from  this  situation  to  the  nerves  of  the 
affected  limbs.  This  plan  is  more  advantageous  than  faradization,  be- 
cause currents  whose  tension  is  too  great  increase  the  excitability  of 
the  centres  and  may  aggravate  the  tremor.  In  tremor  limited  to  the 
hands,  such  as  occurs  in  convalescents  from  typhoid  fever,  and  in  lead 
and  mercurial  poisoning,  the  movements  may  be  made  to  disappear  by 
moderate  stimulation  of  the  muscles  of  the  hand  by  means  of  induced 
currents.  Good  effects  have  also  been  obtained,  in  certain  cases,  by  well- 
regulated  gymnastic  exercises. 

Alcoholic  tremor  is  favorably  influenced  in  the  majority  of  instances 
by  the  use  of  morphine  or  of  extract  of  opium  administered  either  inter- 
nally or  subcutaneously.  Chloral  is  indicated  (three  to  five  grammes  at  a 
dose)  when  the  opium  or  large  doses  of  digitalis  prove  insufficient.  It  is 
necessary,  in  such  cases,  to  resort  to  even  much  larger  doses,  when  the  pa- 
tient is  accustomed  to  strong  spirituous  liquors.  Oulmont  has  obtained 
good  results  from  the  administration  of  hyoscyamine  (0.003-0.012  daily) 
in  several  cases  of  mercurial  and  senile  tremor. 


b.  Paralysis  Agitans. 

Paralysis  agitans  represents  the  most  severe  form  of  tremor.  It  was 
observed  and  carefully  described  for  the  first  time  by  Parki.ison  (Essay 
on  the  Shaking  Palsy,  London,  1817).  The  gravity  of  this  affection  results 
from  its  peculiar  intensity,  from  its  continuous  progress  and  extension, 
and  from  its  termination  in  general  paralysis.  The  tremor  is  a  character- 
istic sign  of  the  decay  of  the  motor  power,  and  it  is  also  the  precursor  of 
the  paralysis. 

The  anatomical  lesions  peculiar  to  paralysis  agitans  are  unknown.  In 
some  cases,  reported  by  Parkinson,  Marshall  Hall,  Oppolzer,  Lebert,  etc., 
indurations  and  hyperplasiiie  were  found  in  the  pons  varolii,  tubercula 
quadrigemina,  and  medulla  oblongata,  but  microscopical  examinations 
were  not  made.     But  if  we  may  judge  from  the   clinical  histories,  these 


110  CLI]!fICAL    TREATISE    ON" 

cases  belong  under  the  category  of  disseminated  sclerosis,  the  symptoms 
of  which  were  unknown  at  that  period.  Foyers  of  softening  in  the  brain 
and  cord,  and  encephalitis  and  sclerosis  of  the  Ammon's  horn  (Chvostek) 
have  been  observed  in  this  disease;  but  these  lesions  must  be  regarded  as 
accidental  complications. 

Greater  importance  is  attached  to  the  changes  recently  observed  in 
three  cases  by  Charcot  and  Joffroy  (Soc.  de  Biol.,  1871). 

In  all  these  cases  there  was  obliteration  of  the  central  canal  from  pro- 
liferation of  the  epithelial  elements,  a  development  of  nuclei  around  the 
canal  and  marked  pigmentation  of  the  nerve-cells,  especially  in  the  col- 
umns of  Clarke;  in  two  cases  the  pons  varolii  contained  masses  of  amy- 
loid corpuscles,  and  in  one  it  was  partially  sclerotic.  Further  investiga- 
tions must  decide  upon  the  pathological  significance  of  these  inflammatory 
changes  in  the  cord  and  other  regions. 

The  onset  of  paralysis  agitans  is  often  preceded  b}'-  prodromata,  such 
as  cerebral  congestion,  chronic  insomnia,  marked  irritability,  muscular 
contractions,  or  temporary  feeling  of  weakness  in  the  limbs.  The  disease 
proper  begins  with  a  slight  trembling,  usually  in  the  upper  limbs.  It  ap- 
pears at  first  in  small  groups  of  muscles,  often  under  the  form  of  slight 
movements  of  pronation  and  supination  of  the  forearm,  which  follow  one 
another  in  rapid  succession.  In  the  beginning  these  involuntary  move- 
ments may  be  completely  controlled  by  the  patient,  or  at  least  diminished 
by  supporting  the  limb  in  which  they  occur;  they  also  cease  during  sleep. 
At  a  later  period  the  trembling  movement  increases  in  intensity,  be- 
comes exaggerated  under  the  influence  of  emotional  excitement,  cold,  and 
effort,  and  extends  to  one-half  of  the  body  (often  beginning  on  the  right 
side).  It  then  extends  to  the  arm  and  leg  of  the  opposite  side  and  to  the 
muscles  of  the  lower  jaw,  lips,  and  tongue.  Paraplegic  and  alternate 
forms  of  tremor  are  very  rare.  If  the  patient  is  placed  in  a  position  of 
extension,  and  the  trunk  is  supported  upon  each  side,  the  tremor  will  be 
arrested  for  a  certain  length  of  time.  The  patients  usually  have  very  im- 
mobile features,  and  the  movements  of  the  eyes  are  very  circvimscribed; 
the  mouth  is  often  filled  with  saliva,  which  is  swallowed  with  difficulty; 
speech  is  difficult  and  sometimes  jerking,  and  the  writing  is  pointed  and 
oblique. 

If  we  carefully  examine  the  motor  functions,  we  will  sooner  or  later 
find  characteristic  disturbances.  The  muscles  of  the  limbs,  trunk,  and, 
most  frequently,  of  the  neck  are  rigid,  and  the  patients  experience  in  them 
a  sensation  of  cramp;  the  voluntary  movements  are  stiff  and  slow  (Char- 
cot). If  the  tonic  tension  predominates  in  the  flexors,  the  neck  and  trunk 
are  inclined  forwards  in  the  vertical  position;  the  upper  limbs  and,  later, 
the  lower  limbs,  assume  a  semi-flexed  position(vide  Fig.  19).  The  thumb 
is  usually  adducted  and  directed  towards  the  palm  of  the  hand,  the  move- 
ments of  the  phalangeal  and  carpal  articulations  are  markedl}^  interfered 
with,  and  the  patients  are  unable  to  carry  the  hand  backwards  to  the  shoul- 
der. In  walking,  the  body  inclines  towards  the  hemiparetic  side.  When  the 
disease  is  prolonged,  a  characteristic  position  of  the  limbs  develops,  as  Char- 
cot has  pointed  out — flexion  of  the  first  phalanges,  forcible  flexion  of  the 
second  phalanges,  and  slight  flexion  of  the  third.  The  gait  is  precipitate 
and  uncertain.  Sauvage  and  Sagar  have  mentioned,  as  a  pathognomonic 
sign,  a  tendency  to  run  and  to  fall  forwards  or  backwards.  This  is  not 
always  noticeable,  is  only  a  complication  of  the  later  periods,  and  is  caused 
by  the  effort  which  the  patient  makes  to  maintain  his  centre  of  gravity 
within  the  base  of  support.     We  can  sometimes  produce  a  movement  of 


DISEASES    OF   THE    NERVOUS    SYSTEM. 


Ill 


I 


recoil  in  the  patients,  by  exercising  a  scarcely  perceptible  traction  upon 
their  clothes  (Charcot).  The  nearer  the  disease  approaches  its  fatal  ter- 
mination, the  more  the  paresis  changes  to  paralysis.  The  tremGr  then  per- 
sists during  sleep,  and  the 
latter  may  be  interrupted  on 
account  of  the  shocks  com- 
municated by  the  patient  to 
the  bed. 

Towards  the  close,  the 
embarrassment  in  speech, 
mastication,  and  deglutition 
terminates  in  complete  abo- 
lition of  these  functions. 

The  following  disorders 
of  sensation  are  observed:  a 
feeling  of  numbness  in  the 
fingers,  neuralgic  pains  in 
the  limbs  affected  with  tre- 
mor, pains  in  the  neck  or 
back  (observed  by  Blasius 
and  Topinard),  sensitiveness 
of  certain  parts  of  the  verte- 
bral column  or  of  the  nerve- 
trunks  to  pressure,  a  sensa- 
tion of  cold  in  the  affected 
limbs,  or  an  abnormal  sensa- 
tion of  heat  without  eleva- 
tion of  temperature  (Char- 
cot). 

Electrical  exploration  dis- 
closes, at  the  onset,  normal 
reactions.  At  an  advanced 
period  of  the  disease,  dimi- 
nution of  electrical  contrac- 
tility occurs  in  the  muscles 
of  the  forearm  and  hand. 
The  galvanic  excitability  of  the  nerves  is  at  first  normal,  but,  at  a  later 
period,  it  is  often  diminished;  the  reaction  is  sometimes  increased  when 
the  symptoms  of  irritation  become  general.  Topinard  published  the  case 
of  a  physician  (Gaz.  des  Hopit.,  21,  18G6)  who  had  illusions  of  sight,  in- 
crease of  sexual  desire,  and  diabetes  mellitus.  Psychical  disorders  occur 
as  terminal  symptoms,  and  are  accompanied  by  loss  of  appetite,  relaxation 
of  the  sphincters,  and  gangrenous  ulcers  of  the  integument.  The  patients' 
die  of  pulmonary  hypostasis  or  oedema,  in  a  condition  of  marasmus,  sopor, 
or  delirium. 

Among  the  causes  of  paralysis  agitans,  we  may  mention  debilitating 
diseases  and  the  prolonged  action  of  cold.  Mental  shocks  (such  as  fright) 
which,  during  the  first  ten  years  of  life,  may  give  rise  to  chorea,  epilepsy, 
or  hysteria  in  predisposed  individuals,  often  cause  paralysis  agitans  at  a 
more  advanced  age.  I  have  seen  a  man,  sixty  years  of  age,  in  whom  a 
carbuncle  of  the  neck  was  opened  ;  he  was  soon  after  seized  with  tremor 
of  the  right  arm,  which  began  when  the  wound  was  dressed,  and  then 
extended  to  the  other  limbs.  When  the  nerve-centres  are  endowed 
with  abnormal  excitability,  either  hereditary  or  acquired  under  the  influ- 


Fio.  19.  —  Attitude  of   patient   suffering   from   paralj-sia 
agitans. 


112  CLINICAL    TREATISE    ON 

ence  of  strong  irritation,  each  period  of  life  presents  peculiar  reactions, 
affecting  chiefly  the  motor  functions.  Double  morbid  forms  are  some- 
times produced,  as  is  shown  by  the  case  reported  on  page  34,  in  which 
hysteria  was  combined  with  symptoms  of  paralysis  agitans.  Among  the 
predisposing  causes,  old  age  holds  the  first  rank.  In  one  case  I  observed 
the  development  of  paralysis  agitans  in  limbs  which  were  paralyzed  in 
consequence  of  cerebral  apoplexy. 

Paralysis  agitans  is  very  often  mistaken  for  tremor  of  various  kinds. 
Careful  observation  will  enable  us  to  arrive  at  an  exact  diagnosis.  The 
points  of  differentiation  from  sclerosis  of  the  nervous  centres  have  been  re- 
ferred to  in  the  chapter  devoted  to  that  affection.  The  distinctions  be- 
tween chorea  and  paralysis  agitans  will  be  discussed  hereafter.  In  senile 
trembling,  not  alone  the  limbs,  but  especially  the  head,  are  agitated  by 
continual  trembling  movements  ;  furthermore,  the  former  is  not  accom- 
panied by  neuralgic  pains,  hemiparesis,  the  characteristic  muscular  stiff- 
ness, the  deformity  of  the  hands,  or  the  tendency  to  movements  of  pro- 
pulsion or  recoil.  Alcoholic  tremor  is  characterized  by  the  excited  con- 
dition of  the  patients,  by  the  delirium  in  which  they  are  pursued  by  all 
kinds  of  imaginary  visions  (especially  by  small  animals)  and  by  the  dimi- 
nution of  the  tremor  under  the  influence  of  stimulants  and  of  large  doses  of 
opium.  Mercurial  tremor  is  almost  always  preceded  by  salivation,  ulcer- 
ations in  the  throat,  swelling  of  the  gums,  foetid  breath,  diarrhoea,  loss  of 
appetite,  and  exhaustion.  Lead  tremor  is  recognized  by  the  previous  oc- 
currence of  lead  colic,  arthralgias,  the  condition  of  the  mouth,  muscular 
paresis,  and  the  partial  abolition  of  electro-muscular  contractility  in  the  ex- 
tensors of  the  arm.  The  tremor  of  opium-eaters  is  accompanied  by  the 
following  symptoms  :  livid  color  of  the  face,  dull  expression,  dull  ej'es, 
markedly  contracted  pupils,  considerable  emaciation,  obstinate  constipa- 
tion, loss  of  appetite,  tendency  to  vertigo,  gloomy  forebodings,  and  uncer- 
tain gait.  The  pror/nosis  of  paralysis  agitans  is  absolutely  unfavorable  in 
the  chronic  or  rapidly  developing  forms.  When  the  disease  is  more  re- 
cent and  less  extended,  it  is  susceptible  of  a  certain  amount  of  improve- 
ment.    Recoveries  are  exceedingly  rare,  and  relapses  are  very  frequent. 

In  the  majority  of  cases  the  treatment  must  be  confined  to  limiting  or 
moderating  some  of  the  symptoms.  Treatment  with  strychnine,  ergotine, 
opium,  curare,  and  extract  of  calabar-bean  have  given  no  encouraging 
results.  Some  authors  have  prescribed  sulphurous  mineral  waters  with  a 
certain  degree  of  benefit.  Elliotson  reports  a  case  of  recovery  from  the 
prolonged  use  of  carbonate  of  iron.  In  recent  cases  the  galvanic  treat- 
ment (stabile  currents  through  the  vertebral  column  and  from  this  region 
to  the  tremulous  limbs)  may  improve  the  tremor  and  the  pains,  but  will 
not  increase  the  strength;  in  the  chronic  forms  electricity  is  useless.  Mild 
hydrotherapeutic  measures  (frictions,  packs  of  short  duration,  cool  half- 
baths  with  dorsal  affusions)  have  a  tonic  action,  and  improve  the  appetite 
and  sleep.  According  to  Charcot,  hyoscyamine  will  moderate  the  symp- 
toms. Eulenburg  has  derived  benefit  from  hypodermic  injections  of 
Fowler's  solution,  but  the  experiments  undertaken  at  the  Salpetriere 
have  not  given  similar  good  results.  Ordenstein  has  found  nitrate  of  sil- 
ver useful. 


DISEASES    OF   THE    NERVOUS    SYSTEM.  113 


CHAPTER  XXXIV. 

CHOREA    AND    ITS    DIFFERENT    FORMS. 

After  having  discussed,  in  the  preceding  chapters,  the  affections  which 
are  characterized  by  spasms  of  cerebral  and  spinal  origin,  we  shall  now 
investigate  another  variety  of  central  motor  disorders,  viz. :  the  affec- 
tions of  co-ordination.  As  we  have  shown  in  the  consideration  of  the 
theory  of  ataxia,  we  find,  in  a  series  of  pathological  conditions,  serious 
disturbances  affecting  the  centres  of  co-ordination  in  the  cerebellum  and 
mesocephalon  and  in  the  sensory  conductors  which  these  organs  send  into 
the  posterior  columns  of  the  cord.  Disorders  of  co-ordination  will  result 
from  solutions  of  continuity  in  the  relations  of  these  centres  with  the 
spinal  system  of  ganglion-cells  and  from  serious  obstacles  to  the  ti-ans- 
mission  of  motor  impulses  starting  from  the  cerebral  ganglia. 

In  accordance  with  the  principles  previously  laid  down,  we  shall  de- 
scribe as  disorders  of  co-ordination,  those  motor  disturbances  in  which 
the  harmonious  action  of  certain  muscles,  or  of  certain  groups  of  muscles, 
in  performing  definite  movements,  is  interfered  with,  while  the  isolated 
action  of  each  muscle  remains  intact.  In  the  diseases  which  we  shall 
study  from  this  point  of  view,  the  conductors  of  co-ordination  may  un- 
dergo, in  their  long  course,  disorders  of  great  extent  (as  in  chorea),  or 
merely  circumscribed  lesions  (as  in  writer's  spasm,  and  stammering). 

A. — Chorea  Magna. 

Chorea  magna  results  from  a  condition  of  irritation  of  certain  centres 
of  co-ordination  and  of  the  centrifugal  conductors  which  connect  the 
cells  of  the  cerebral  cortex  with  the  motor  apparatus.  Future  histological 
investigations,  when  carefully  performed,  will  undoubtedly  discover,  in 
chorea  magna  and  minor,  exudations  around  the  vessels  in  the  cortical 
and  medullary  substance  of  the  brain  and  in  the  conductors  of  the  cord, 
and  this  will  explain  the  combination  of  psychical  disorders  with  disturb- 
ances of  co-ordination. 

Chorea  magna  (chorea  Germanorum)  consists  of  spasmodic  move- 
ments, occurring  paroxysmally  in  certain  groups  of  muscles,  and  present- 
ing the  appearances  of  voluntary  motor  direction.  The  movements  are 
sometimes  simple,  sometimes  complex.  In  this  affection  the  patients 
execute,  against  their  will,  extraordinary  combinations  of  movements 
which  it  is  extremely  difficult  to  perform  in  the  normal  condition,  and 
which  are  repeated  under  the  influence  of  peculiar  psychical  stimuli. 

Symptomatology. 

The  symptoms  of  chorea  may  present  a  great  variety  of  aspects.     In 
the  majority  of  cases   the  paroxysm  is  preceded  by  prodromata,  consist- 
VoL.  II.— 8 


114  CLINICAL    TREATISE    ON 

ing  of  irritative  symptoms  of  motion,  sensation,  or  of  the  psychical 
functions.  Isolated  muscular  contractions,  tremors,  nausea,  cephalalgia 
or  rachialgia,  palpitation  of  the  heart,  difficulty  of  respiration,  painful 
sensations,  agitation,  illusions  and  visions  are  the  most  frequent  prodro- 
mata  of  the  attack.     But  in  some  cases  the  latter  develops  suddenly. 

The  paroxysm,  properly  speaking,  consists  of  a  series  of  movements 
"which  vary  greatly  in  character  and  intensity,  according  to  the  groups  of 
muscles  which  are  the  seat  of  the  involuntary  actions.  The  patients  run, 
jump,  hop,  dance,  climb,  whirl  around,  stamp  with  the  feet,  cry  like 
animals,  exercise  like  acrobats,  declaim  like  actors,  sing,  recite  poetry 
(even  in  a  foreign  language),  etc.  They  expend  in  all  these  actions  an 
extraordinary  amount  of  force,  and  manifest  an  address  and  dexterity 
which  they  are  incapable  of  when  performing  similar  acts  in  their  normal 
condition.  The  paroxysm  may  present  the  same  characteristics  during 
its  entire  duration,  or  it  may  appear  in  various  phases. 

In  severe  conditions,  accompanied  by  ecstasy,  the  patients  suffer  from 
anaesthesia  and  analgesia,  tremors,  contractures,  pareses  or  paralyses,  and 
cataleptic  or  tetanic  symptoms,  attended  with  loss  of  reflex  excitability. 
Consciousness  and  the  functions  of  the  special  senses  are  clouded  in  a 
great  measure.  In  less  severe  cases  the  senses  and  psychical  faculties 
are  less  involved;  the  patients  are  conscious  of  their  acts  and,  now  and 
then,  may  even  perform  voluntary  movements.  In  some  patients  inten- 
sified acuteness  of  the  sensorial  perceptions  and  an  increase  in  the  in- 
tellectual activity  are  observed,  but  this  is  always  proportionate  to  the 
general  education  of  the  individual.  In  certain  conditions  of  exaltation 
the  patients  hold  discourses  and  compose  poetry  with  surprising  facility; 
their  sad  ideas  and  presentiments  are  converted  into  images  of  clairvoy- 
ance. Blinded  by  these  unaccustomed  phenomena,  and  encouraged  by 
those  around  them,  these  patients  give  free  rein  to  the  imagination,  and 
increase,  by  their  recitals,  the  mystical  character  of  the  disease. 

The  paroxysm  may  terminate  suddenly  or  may  slowly  disappear.  The 
phenomena  of  exaltation  and  the  spasmodic  symptoms  then  cease,  and 
the  patients,  tired  in  mind  and  body,  sleep  for  a  longer  or  shorter  period. 
In  light  forms  the  return  to  the  normal  condition  occurs  after  the  spas- 
modic symptoms  have  lasted  for  a  short  time.  At  other  times  the 
patients  are  greatly  fatigued,  ill  at  ease,  and  in  bad  humor,  and  only  re- 
cover after  the  lapse  of  a  few  days.  The  attacks  may  develop  at  any 
hour  of  the  day  or  night,  without  adhering  to  a  definite  type,  but,  on  the 
other  hand,  they  sometimes  present  the  most  remarkable  regularity.  One 
of  my  patients  could  tell  in  the  morning  whether  the  attack,  which  oc- 
curred the  same  night,  would  be  strong  or  weak;  she  was  able  to  foretell 
this,  as  she  stated,  by  a  sensation  of  tension  in  the  nerves. 

The  duration  of  the  paroxysms  varies  from  a  few  minutes  to  several 
hours.  In  very  rare  instances  it  may  continue  for  several  days,  but  re- 
missions always  occur  in  these  cases.  Franque  has  published  (Journ.  f. 
Kinderheilk.,  1867,  p.  226)  the  history  of  a  case  of  chorea  lasting  two 
and  a  half  years,  in  a  boy  affected  with  movements  of  rotation,  skipping, 
and  jumping;  after  the  attacks  the  urine  contained  sugar,  but  was  nor- 
mal during  the  intervals.  In  another  case,  sugar  was  also  found  in  the 
urine  of  a  woman  suffering  from  chorea  magna,  but  only  after  the  cessa- 
tion of  the  paroxysms.  In  most  cases  the  disease  terminates  after  a  cer- 
tain lapse  of  time.  But,  as  a  rule,  an  abnormal  irritability  of  the  nervous 
system,  which  predisposes  the  patients  to  various  affections,  usually 
persists  for  a  long   time  and  often   even  for  life.     Some  patients  suffer 


DISEASES    OF   THE    NERVOUS    SYSTEM.  115 

from  hysteria,  and,  in  exceptional  instances,  from  epilepsy  or  insanity. 
The  disease  very  rarely  terminates  in  death,  and  this  event  is  almost 
always  due  to  complications  or  to  exhaustion. 

The  gross  anatomical  lesions  which  have  been  found  in  chorea  magna 
are  :  venous  hyperasmia  of  the  brain  and  cord,  meningeal  haemorrhages, 
inflammatory  thickenings  of  the  spinal  nerves  (Day),  softening  of  the 
cord  (Vecchietti).  These  data  throw  no  light,  however,  upon  the  nature 
of  the  disease. 

Etiology. 

Chorea  magna  occurs  especially  in  those  individuals  who  have  in- 
herited a  peculiar  morbid  susceptibility,  or  in  whom  this  condition  has 
developed  during  the  period  of  puberty.  According  to  Wicke's  statis- 
tics (Monogr.  des  gr.  Veitstanzes,  etc.,  Leipzig,  1864),  among  one  hundred 
and  sevQBi  patients,  chorea  developed  eighty-four  times  from  the  tenth 
to  the  twentieth  years,  and  sixty-two  times  from  the  tenth  to  the  six- 
teenth years.  Two-thirds  of  the  patients  were  females.  The  etiological 
factors  of  chorea  include  the  following:  psychical  excitement,  liaisons, 
sexual  irritation,  onanism,  menstrual  disorders,  and  chlorosis.  From  the 
etiology  and  the  undeniable  resemblance  in  the  principal  symptoms  of 
the  disease,  we  are  justified  in  regarding  chorea  magna  as  very  closely 
allied  to  hysteria. 

Religious  exaltation  may  also  give  rise  to  chorea  magna.  Many 
authors  attribute  to  this  cause  the  epidemics  of  Saint  Guy's  dance,  which 
were  observed  during  the  Mi^ddle  Ages.  But,  as  Hecker  has  shown  (Mala- 
dies populaires  du  Moyen  Age),  this  disease  was  a  form  of  insanity,  ac- 
companied by  severe  convulsive  and  ecstatic  manifestations.  Within  our 
own  times  Davidson  (Edinb.  Med.  Journ.,  1867,  t.  XIII.,  p.  124)  has  de- 
scribed an  epidemic  of  choreomania  appearing  in  Madagascar.  Par- 
oxysms of  dancing,  combined  with  rotatory  movements  of  the  head  and 
raising  and  lowering  of  the  arms,  which  lasted  even  for  hours,  occurred 
among  the  lower  and  superstitious  classes,  who  were  excited  by  social  and 
political  changes,  and  especially  among  young  females.  This  was  rather 
a  form  of  mania  than  of  chorea.  Cantani  states  (II  Morgagni,  1872) 
that  chorea  magna  is  frequently  observed  in  southern  Italy. 


Diagnosis  and  Prognosis. 

If  we  glance  over  the  cases  described  by  various  authors,  we  will  find 
that  they  have  confounded,  under  the  term  chorea  magna,  examples  of 
convulsions  attended  with  exaltation,  insanity,  saltatory  spasms,  and  even 
certain  forms  of  chorea  minor  of  a  slow  course,  which  were  attended  by 
intermittent  exacerbations. 

Chorea  magna  is  distinguished  from  insanity  properly  speaking,  by 
the  paroxysmal  appearance  of  irresistible  motor  impulses,  by  the  frequent 
coexistence  of  partial  tonic  and  clonic  convulsions,  by  its  appearance  at 
the  period  of  puberty,  usually  after  mental  excitement,  and  by  the  fre- 
quency of  hysterical  manifestations,  intermingled  with  the  other  symp- 
toms. Saltatory  spasms  (of  which  Bamberger  described  two  cases  in 
1859,  and  Guttmann  another  more  recently)  have  the  following  character- 
istics: as  soon  as  the  patient,  while  in  the  vertical  position,  touches  the 
ground   with   his  feet,  his  body  is   rapidly  tossed   into    the  air.     These 


116  CLINICAL   TREATISE    ON 

spasms  are  of  a  reflex  nature  and  probably  due  to  spinal  irritation.  In 
chorea  minor,  there  are  no  periodical  attacks,  the  tonic  muscular  spasms 
and  associated  movements  are  made  without  the  appearance  of  any  vol- 
untary impulse,  the  psychical  functions  are  affected  more  rarely  and  to  a 
slighter  degree,  and  the  co-ordination  of  movements  presents  more 
marked  disturbances.  In  somnambulism,  which  we  have  described  as  a 
variety  of  hysteria,  alienation  of  the  psychical  functions,  and  phenomena 
of  inco-ordination  also  occur.  But,  in  this  affection,  the  attacks  only  oc- 
cur during  sleep,  and  the  movements  do  not  assume  the  spasmodic  char- 
acter which  they  present  in  chorea. 

The  jjrognosis  of  chorea  magna  depends  upon  the  intensity  and  dura- 
tion of  the  affection.  If  it  has  not  assumed  a  very  chronic  character,  and 
if  the  nutrition  has  suffered  but  little,  the  termination  of  the  period  of 
puberty,  marriage,  or  improved  habits  of  life,  may  cause  the  spontaneous 
disappearance  of  the  disease.  The  severe  forms,  which  run  a  chronic 
course,  compromise  nutrition,  and  lead  to  anaemia  and  cachexia.  Al- 
though life  itself  is  only  endangered  in  very  rare  cases,  nevertheless,  in 
inveterate  forms,  the  prognosis  is  grave,  and  is  rendered  so  much  the 
more  so,  because  the  disease  may  run  its  obstinate  course  for  years,  re- 
lapses occur  upon  slight  provocation,  and  the  physical  and  mental  condi- 
tion of  the  patients  is  seriously  affected.  The  transition  from  chorea  to 
insanity,  properly  speaking,  or  to  epilepsy,  is  a  rare  event;  the  disease  is 
much  more  frequently  followed  by  hysterical  phenomena. 


Treatme7it. 

The  anaemia  and  neuropathic  condition  which  are  found  in  the  major- 
ity of  the  patients  demand,  above  all,  tonic  remedies.  We  may  recom- 
mend mild  preparations  of  iron,  ferruginous  baths  and  mineral  waters,  a 
prolonged  stay  in  the  exhilarating  air  of  the  country,  and  moderate  exer- 
cise in  the  open  air.  Narcotics  are  usually  but  poorly  tolerated  by  the 
patients;  we  should  reserve  them  as  adjuvants  in  violent  and  painful 
paroxysms.  The  salts  of  zinc,  in  large  doses,  have  been  recently  recom- 
mended, especially  by  Stunde.  The  antispasmodics  are  sometimes  capa- 
ble of  moderating  the  attacks. 

In  severe  forms,  we  may,  at  times,  suspend  the  paroxysms  by  the  use 
of  quinine  administered  for  a  long  time  in  large  doses  (two  to  three 
grammes  daily.)  It  is  worthy  of  remark  that  symptoms  of  poisoning  are 
never  observed  in  these  cases.  I  have  employed  the  nitrate  of  silver  in 
one  case  ("  hammering,"  chorea  of  several  months'  duration,  in  a  young 
man  who  also  suffered  from  infiltration  into  the  apices  of  both  lungs). 
At  the  end  of  the  eighth  day  of  this  plan  of  treatment  (0.01-0.03  daily), 
the  paroxysms  had  disappeared  and,  the  use  of  the  drug  having  been 
continued,  had  not  returned  at  the  end  of  several  months.  I  had  em- 
ployed atropine  in  this  patient,  as  well  as  in  another  case,  without  any 
favorable  results.  We  may  add,  in  conclusion,  that  judicious  moral 
treatment,  the  removal  of  all  sources  of  worry,  an  appeal  to  the  will  of  the 
patient,  and  mild  hydro-therapeutic  measures,  very  frequently  render 
good  services.  We  must  avoid  the  exciting  applications  of  cold  water, 
and  should  give  the  preference  to  partial  frictions  of  the  limbs,  cool  half- 
baths,  dorsal  affusions,  and  later  to  moist  frictions. 


DISEASES    OF    THE    NERVOUS    SYSTEM.  117 


B. — Chorea   Minoe. 

This  disease  has  been  recognized  for  centuries,  but  it  is  only  within 
recent  times  that  its  central  origin  has  been  discovered  by  a  resort  to  ex- 
perimentation and  pathological  anatomy. 

Chorea  minor  (chorea  Anglorum)  consists  of  more  or  less  continuous 
muscular  contractions  and  associated  movements,  which  occur  without 
disturbances  of  consciousness,  especially  under  the  influence  of  voluntary 
motor  impulses,  and  without  any  apparent  aim  in  view,  that  is  to  say, 
with  inco-ordination.  This  definition  comprises  the  most  characteristic 
signs  of  chorea,  leaving  out  of  consideration  the  accessory  symptoms. 
It  applies  equally  to  the  various  forms  of  chorea  minor,  whether  of  an 
idiopathic,  or  of  a  secondary,  symptomatic  or  reflex  nature. 


Pathological  Anatomy  and  Experimental  Investigations. 

In  the  old  observations  of  Cruveilhier,  Romberg,  etc.,  foyers  of  soft- 
ening were  found  in  various  parts  of  the  brain.  Among  more  modern 
authors,  Broadbent  (Brit.  Med.  Jour.,  April,  1869),  followed  by  Tuck- 
well,  Ogle,  Russell  and  Hughlings  Jackson,  have  observed  in  chorea  the 
presence  of  capillary  emboli  in  the  corpus  striatum  and  optic  thalamus,  and 
the  production  of  granular  cells  around  the  vessels.  Aitken  found  the 
specific  gravity  of  the  corpus  striatum  and  optic  thalamus  very  much 
diminished  in  proportion  to  the  specific  gravity  of  other  parts  of  the 
brain.  In  the  spinal  cord,  the  new-formed  connective  tissue,  which  has 
been  found  in  other  acute  diseases  attended  with  spasms,  was  observed 
for  the  first  time  in  chorea  by  Rokitansky.  Brown-Sequard  and  Gendron 
have  noticed  softening  of  the  cord.  Tuckwell  (Brit.  Med.-Chir.  Rev., 
18G7)  found  in  a  choreic  patient  who  suffered  from  vegetations  of  the 
heart-valves,  foyers  of  embolic  softening  in  the  cerebral  hemispheres  and 
cortical  substance,  and  in  the  posterior  columns  of  the  cord  (cervical  and 
dorsal  regions).  L.  Clarke  (eod.  loc,  18G8)  found  softening  of  the 
cord,  in  addition  to  granular  exudation  into  the  corpus  striatum. 

In  a  case  of  chorea  reported  by  Meynert  (Ztschr.  der  Wien.  Ges.  d. 
Aerzte,  Feb.,  1868),  microscopical  examination  showed  that  a  large  num- 
ber of  the  cells  of  the  cerebral  cortex  were  in  a  condition  of  dropsical  en- 
largement, with  molecular  degeneration  of  the  protoplasm;  there  was  par- 
tial sclerosis  of  the  cells  in  the  cortex  of  the  insula  and  in  the  cerebral 
ganglia,  with  considerable  proliferation  of  the  nuclei  of  the  nerve-cells; 
proliferation  of  the  nuclei  of  the  connective  tissue  in  the  medullary  sub- 
stance situated  between  the  ganglia;  the  cells  of  the  reticulum  of  the 
cord  were  enlarged.  Elischer  (Virch.  Arch.,  Bd.  61,  1874)  has  recently 
observed  the  following  lesions  in  a  pregnant  woman  who  had  suffered 
from  chorea:  in  the  corpus  striatum,  nuclear  proliferation,  hyperplasia  of 
the  connective  tissue,  tliickening  of  the  tunica  adventitia  of  the  small 
vessels;  the  same  changes  in  the  tunica  interna  of  the  vessels  of  the  len- 
ticular nucleus;  division  of  the  nuclei  of  the  nerve-cells  in  the  claustrum. 
The  spinal  cord  presented  thickening  and  nuclear  proliferation  in  the  walls 
of  the  vessels,  inflammatory  changes  in  the  epithelium  of  the  central  canal, 
and  nuclear  proliferation  in  the  connective  tissue  around  the  nerve-cells 
of  the  gray  matter;  the  latter  presented  a  dull  appearance,  were  destitute 
of  nuclei,  and  filled  with  pigment;  the  white  substance  was  hyperwmic; 


118  CLINICAL    TREATISE    ON 

the  lateral  and  posterior  columns  contained  a  fibrillary  tissue  strewn  with 
nuclei.  In  the  peripheral  nerves,  the  fibres  were  diminished  in  number, 
and  a  large  amount  of  connective  tissue  was  interposed  between  them; 
there  were  small  haemorrhages  in  the  interstices  of  this  tissue. 

Chauveau  performed  some  very  interesting  experiments  (Arch,  gener., 
Mars,  1865)  several  years  ago,  with  regard  to  the  localization  of  the  le- 
sions which  give  rise  to  choreic  movements.  In  an  animal  which  suffered 
from  general  chorea,  the  cord  was  divided  near  its  junction  with  the  brain, 
and  the  movements  persisted  for  several  hours  until  death,  without  being 
lessened  in  intensity  or  otherwise  modified.  The  choreic  movements 
were,  therefore,  not  dependent  upon  the  brain  or  cerebellum.  In  two  other 
choreic  dogs  who  were  also  affected  with  partial  paralysis  and  atrophy  of 
the  upper  limbs,  section  of  the  cord,  performed  as  in  the  preceding  experi- 
ment, also  produced  no  effect  upon  the  movements.  But,  after  section 
of  the  dorsal  cord,  the  convulsive  movements  of  the  tail  and  lower  limbs 
diminished,  the  muscles  remaining  sensitive  to  mechanical  irritations. 

At  the  autopsy,  the  muscles  were  found  atrophied  but  not  degener- 
ated, and  the  nerve-fibres  were  intact.  The  cessation  of  the  movements 
coincidently  with  the  arrest  of  the  cardiac  pulsations  and  with  the  inci- 
sion of  the  dorsal  cord,  prove,  according  to  Chauveau,  that  the  morbid 
process  in  chorea  is  located  in  the  spinal  cord.  The  experiments  per- 
formed by  Longet,  Bert,  and  Clarville,  lead  to  the  same  conclusion. 

Legros  and  Onimus,  at  a  later  period,  began  another  series  of  experi- 
ments upon  choreic  dogs  (Compt.  Rend.,  t.  LXX.,  1870).  Upon  expos- 
ing the  spinal  cord  and  irritating  the  posterior  columns  with  a  scalpel,  the 
choreic  movements  were  found  to  become  enormously  intensified.  They 
disappeared  if  the  cord  was  chilled  by  means  of  a  current  of  air,  but  soon 
returned  after  an  application  of  warm  water.  The  movements  were  not 
diminished  by  excision  of  the  posterior  roots,  but  only  after  partial  ex- 
cision of  the  posterior  columns  and  horns;  if  a  deeper  incision  was  made, 
the  movements  ceased  completely.  The  application  of  a  constant  current 
to  the  cord  increased  the  chorea,  while  electrical  irritation  of  the  periphery 
diminished  the  intensity  and  frequency  of  the  movements.  The  induced 
current  gave  rise  to  tetanic  muscular  contractions.  From,  these  experi- 
ments Legros  and  Onimus  concluded  that  the  site  of  chorea  is  either  in 
the  nerve-cells  of  the  posterior  horns,  or  in  the  fibres  which  connect  them 
with  the  motor  cells.  The  influence  of  the  brain  upon  choreic  movements 
(chorea  following  apoplexy  or  softening),  which  has  been  demonstrated 
by  pathological  observations,  has  been  still  further  confirmed  by  the  fol- 
lowing experiment,  performed  in  the  Vienna  Institute  of  Experimental 
Pathology.  With  a  view  of  producing  cerebral  embolism  an  injection  of 
pollen  was  made  into  the  left  internal  carotid  of  a  dog  who  had  suffered 
for  some  time  from  choreiform  movements,  especially  in  the  right  anterior 
limb.  After  the  experiment  was  made,  the  animal  wa.s  unable  to  rise  or 
change  his  position.  Despite  the  abolition  of  voluntary  movements,  how- 
ever, violent  choreic  covulsions  occurred  in  the  anterior  limbs,  in  the  eyes 
and  tail,  and  continued  for  two  days  until  the  death  of  the  animal. 
Autopsy  :  encephalitis  of  the  left  anterior  lobe,  softening  of  the  left 
corpus  striatum,  embolism  of  the  left  middle  cerebral  Artery.  Microscopi- 
cal examination  of  the  cerebral  substance  showed  the  existence  in  several 
places  of  depots  of  connective  tissue  proliferation. 

The  disorders  experimentally  produced  in  the  cerebral  circulation  were 
therefore  followed,  on^account  of  the  suspension  of  the  functions  of  the 
motor  ganglia,  by  an  increase  in  the  choreic  movements,  probably  from 


DISEASES    or    TUE    NEKVOUS    SYSTEM.  119 

irritation  of  the  centres  of  co-ordination  situated  in  tlie  mesocephalon  and 
cerebellum. 

Syrtxptonxatology. 

The  prodromata  are  not  constant,  and  consist  of  intellectual  malaise, 
abnormal  excitability,  palpitation  of  the  heart,  temporary  vertigo,  and 
exhaustion.  The  first  muscular  contractions  usually  occur  in  the  muscles 
of  the  face,  shoulders,  and  hands  (the  children  are  often  accused  of  being 
naughty) ;  they  then  involve  the  upper  and  lower  halves  of  the  body. 
Both  sides  of  the  body  are  often  affected,  though  one  is  more  severely  in- 
volved than  the  other;  sometimes  hemichorea  alone  develops.  According 
to  See  (Mem.  de  I'Acad.  de  Med.,  1850,  t.  XV.,  p.  373),  among  one  hun- 
dred and  nfty-four  cases  the  chorea  occurred  ninety-seven  times  iipon  the 
left  side,  either  exclusively  or  predominantly. 

The  choreic  movements  may  involve  all  the  muscles  of  organic  life 
with  the  exception  of  the  inferior  sphincters.  They  are  manifested  by 
contortions  of  the  head  and  trunk,  grimaces  of  the  face,  rotation  of  the 
eyes,  strabismus,  incessant  movements  of  the  tongue,  and  shoulders;  the 
arms  and  hands  are  moved  and  twisted  hither  and  thither,  and  are  flexed 
and  extended. 

While  walking  the  legs  trip  and  bend  under.  This  peculiar  condition 
of  muscular  agitation  has  been  called  "  folic  musculaire  "  by  Bouillaud, 
and  "insanity  of  muscles"  by  Bellingham. 

In  light  forms  these  muscular  symptoms  are  very  moderate,  but,  in 
cases  of  considerable  intensity,  the  performance  of  combined  movements 
becomes  almost  impossible.  The  patients  are  unable  to  maintain  the  erect 
posture  and  the  body  is  thrown  in  all  directions;  when  lying  down  they 
are  in  danger  of  falling  out  of  bed,  and  involuntarily  disarrange  the  bed- 
clothes. The  skin,  which  is  subject  to  continual  friction,  becomes  irritated, 
especially  over  bony  projections;  the  tongue  and  lips  are  sometimes 
severely  bitten.  These  irregular  convulsions  of  the  muscles  may  continue 
uninterruptedly  during  the  day.  As  a  rule,  the  patients  obtain  very 
little  rest  and  sleep  at  night;  they  are  disturbed  by  dreams,  toss  in  bed,, 
and  start  up  out  of  sleep. 

Voluntary  acts  are  performed  with  difficulty,  as  the  active  move- 
ments are  disturbed  by  the  contractions  of  the  antagonistic  or  adjacent 
muscles.  These  additional  movements  cause  the  patients  to  experience 
great  difficulty  in  their  ordinary  occupations.  It  is  only  with  great  ex- 
ertion that  they  are  able  to  eat,  write,  sew,  or  perform  upon  musical 
instruments.  The  respiratory  movements  are  irregular,  speech  is  embar- 
rassed, and  the  pulse  is  often  accelerated.  These  phenomena  are  due  to 
the  spasmodic  action  of  the  muscles  of  respiration,  of  the  larynx,  pharynx, 
and  perhaps  also  of  the  heart.  It  is  true  that  the  patients  are  voluntarily 
able  to  suppress  the  spasmodic  movements  for  a  certain  length  of  time, 
but  this  effort  of  the  will  reacts  as  a  cause  of  irritation,  and  produces  a 
subsequent  increase  in  the  intensity  of  the  muscular  disorder.  A  similar 
result  is  produced  when  the  violence  of  the  muscular  action  is  passively 
restrained.  In  one  case  of  chorea  I  observed,  at  the  height  of  the 
paroxysms,  a  very  marked  dilatation  of  both  pupils.  This  was  not  modi- 
fied by  exposure  to  light  or  by  the  introduction  of  a  thin  electrode  be- 
tween the  sclerotic  and  conjunctiva.  The  symptom  disappeared  sponta- 
neously after  the  termination  of  the  attack  (spasm  of  the  dilator  of  the 
pupils  from  irritation  of  the  cilio-spinal  centre). 


120  CLIlSnCAL   TREATISE    OS 

Sensibility  is  remarkably  increased,  especially  at  the  onset  of  severe 
attacks.  The  skin  is  hypergesthetic,  and  pricking,  pinching  or  electrical 
irritation  produce  acute  sensibility  and  reflex  movements.  The  vertebral 
column  is  extremely  sensitive  to  pressure,  especially  in  the  cervical  and 
upper  dorsal  regions.  Constriction  of  the  head,  and  a  feeling  of  exhaus- 
tion, are  often   experienced,  when  the  muscular  contortions  are  prolonged. 

The  psychical  faculties  are  also  more  or  less  affected,  and  this  fact  is 
explained  by  the  changes  found  by  Meynert  in  the  cerebral  cortex.  J. 
Frank,  Romberg,  Hasse,  Skoda,  have  observed  mental  disturbances  in  the 
course  of  chorea  minor.  Marce,  in  his  Memoire  to  the  Academy,  refers 
to  cases  of  this  character,  and  Leidesdorf  has  recently  called  attention  to 
the  feelings  of  dread,  the  hallucinations  of  the  senses,  and  especially  of 
sight,  which  occur  in  certain  choreics.  If  febrile  complications  co-exist, 
the  intellectual  disorders  must  not  be  attributed  to  chorea  alone.  I  have 
observed  several  cases  of  simple  chorea  attended  with  weakness  of  mem- 
ory, marked  diminution  of  the  intellectual  powers,  and  inability  to 
carry  on  a  logical  train  of  thought.  One  woman  who  suffered  from 
chorea,  which  had  developed  after  a  previous  confinement,  presented  un- 
usual jactitation  and  loquacity,  and  often  gave  utterance  to  savage  cries, 
though  entirely  conscious.  This  condition  was  moderated  b}'^  inhalations 
of  chloroform  (administered  until  complete  narcosis  was  produced),  and, 
at  a  later  period,  the  patient  recovered  from  the  chorea,  after  having 
safely  passed  through  an  attack  of  variola. 

I  have  resorted  to  electrical  exploration  in  three  cases  of  unilateral  chorea, 
observed  soon  after  the  onset,  and  have  found  a  marked  increase  of  the 
electro-muscular  contractility  (with  a  weak  current,  and  compared  with 
the  healthy  side  or  with  other  patients  of  the  same  age).  I  have  also  ob- 
served very  marked  galvanic  excitability,  manifesting  itself  by  contrac- 
tions upon  making  the  current  at  the  negative  pole,  by  galvano-tonic 
contractions  with  weak  currents,  and  by  contractions  upon  breaking  the 
current  of  the  cathode.  The  increase  in  the  irritability  of  the  sensory 
nerves  is  shown  by  the  exaggerated  sensibility  of  the  skin  to  the  ac- 
tion of  the  current,  and  by  the  fact  that,  when  the  poles  of  a  constant 
or  induced  current  are  placed  upon  the  cervical  or  lower  dorsal  region  of 
the  vertebral  column,  excentric  sensations  are  produced,  either  in  the  fin- 
gers or  in  the  knees  or  toes;  on  one  occasion,  indeed,  these  sensations 
were  crossed. 

Chorea  generally  runs  a  chronic  course,  and  often  lasts  from  six  to 
eight  weeks  ;  severe  cases  may  continue  four  or  five  months.  The  cases 
observed  by  certain  authors,  in  which  the  chorea  has  lasted  for  several 
years  or  even  for  a  great  part  of  the  patient's  life,  were  probably  caused 
by  organic  lesions  in  the  brain.  This  is  probably  also  true  of  those  pa- 
tients to  whom  Trousseau  has  called  attention,  and  in  whom  hemiplegia 
followed  an  attack  of  chorea  occurring  in  early  life.  In  several  cases  of 
chorea  I  have  observed  temporary  pareses  of  the  limbs. 


Etiology. 

In  enumerating  the  predisposing  causes  of  chorea,  I  must  call  especial 
attention  to  the  hereditary  irritability  of  the  co-ordinating  apparatus. 
This  disposition  is  not  always  shown  by  the  direct  transmission  of  choreic 
affections,  but  by  the  existence  of  other  nervous  diseases  in  the  parents 
or  other  members  of  the  family.     The  abnormal  irritability  of  the  centres 


DISEASES    OF   THE    NERVOUS    SYSTEM.  121 

of  co-ordination  is  only  an  exaggeration  of  the  general  excitability  of  the 
nervous  system,  which  always  exists  in  such  cases  in  the  young  people, 
and  which  is  manifested  by  extraordinary  vivacity,  precocious  intellectual 
development,  brusquesness  and  impatience. 

Age  also  constitutes  one  of  the  predisposing  causes  of  chorea.  Ac- 
cording to  the  statistics  collected  by  See  and  others,  a  large  proportion  of 
cases  (about  one-third)  belongs  to  the  period  comprised  between  second 
dentition  and  puberty.  Only  isolated  cases  occur  at  a  more  advanced 
age.  According  to  Levick,  chorea  is  observed  more  frequently  among 
the  lower  than  among  the  better  classes  of  the  population.  Sex  ex- 
ercises a  great  influence  upon  the  development  of  chorea,  since,  accord- 
ing to  See,  three-fourths  of  the  cases  observed  in  the  Children's  Hospital 
of  Paris  occurred  in  girls.  Ana3mia,  chlorosis,  menstrual  disorders, 
psychical  affections  and  pregnancy,  which  give  rise  to  hysteria  in  predis- 
posed individuals,  may  also  favor  the  development  of  choreic  symptoms. 

The  relations  of  chorea  to  rheumatism  have  been  recognized  since  the 
beginning  of  this  century.  The  appearance  of  cardiac  bruits  during  this 
disease  was  noticed  by  Addison,  and  at  a  later  period  by  Todd.  Romberg 
and  Grisolle  considered  rheumatism  and  cardiac  affections  as  mere  acci- 
dental complications  of  chorea,  but  Watson  demonstrated,  from  an  analy- 
sis of  three  hundred  and  nine  cases  observed  by  Hughes,  and  thirty-six  by 
Kirkes,  that  in  twelve  fatal  cases  the  heart  was  found  diseased  ten  times, 
and  that  among  one  hundred  and  four  carefully  observed  cases,  only  fif- 
teen were  free  from  cardiac  bruits  or  rheumatism. 

Among  one  hundred  and  twenty-eight  children  affected  with  chorea, 
See  (loc.  cit.)  found  sixty-four  cases  of  acute  articular  rheumatism,  a  fact 
which  is  so  much  the  more  important  because  rheumatism,  as  we  well  know, 
is  very  infrequent  among  children. 

Senhouse,  Heslop  and  Roger,  have  endeavored  clinically  to  establish 
the  relations  existing  between  chorea  and  rheumatism,  pericarditis  and 
endocarditis,  holding  that  both  affections  are  the  common  expression  of 
one  and  the  same  pathological  condition.  According  to  Roger,  chorea 
almost  always  makes  its  appearance  in  children  during  the  period  of  de- 
cline of  the  articular  rheumatism.  As  a  rule,  the  rheumatism  is  neither 
violent  nor  obstinate.  The  more  acute,  severe,  and  extensive  the  articu- 
lar affection,  and  the  more  it  is  complicated,  either  in  the  beginning  or 
at  a  later  period,  with  cardiac  affections,  the  slighter  will  be  the  choreic 
manifestations. 

According  to  the  observations  made  at  Prague  by  Steiner  (Prag. 
Vjschr.,  Bd.  ITI.,  1868),  this  pathological  relation  does  not  possess  an  ab- 
solute value,  since  among  two  hundred  and  fifty-two  cases  of  chorea,  only 
four  appeared  during  the  course  of  acute  articular  rheumatism.  It  is 
therefore  probable  that,  under  the  influence  of  local  causes,  the  coinci- 
dence of  the  two  diseases  is  observed  more  frequently  in  certain  coun- 
tries, and  that  certain  conditions  render  the  action  of  the  rheumatic  in- 
flammation upon  the  serous  membranes,  the  articulations,  spinal  meninges 
and  centres  of  co-ordination,  more  frequent  and  intense. 

According  to  Hughes  and  Trousseau,  chorea  occurs  frequently  after 
scarlatina.  This  fact  is  probably  accounted  for  by  the  relations  existing 
between  rheumatism  and  scarlatina,  for,  according  to  Trousseau,  one-third 
of  the  cases  of  scarlatina  are  also  subject  to  articular  affections  (light 
forms)  and  sometimes  even  to  endocarditis  and  pericarditis.  In  conclu- 
sion we  may  state  that  certain  English  physicians  (Todd,  Smith,  Beale), 
in  order  to  prove  the  rheumatic   origin  of  chorea,  refer  to  the  fact  that 


122  CLINICAL    TREATISE    ON" 

the  urine  presents  the  characteristics  of  the  rheumatic  diathesis,  viz.:  liigh 
specific  gravity  and  a  considerable  quantity  of  urea,  urates  and  oxalate 
of  lime. 


Nature  of  Chorea. 

It  is  evident  from  the  clinical  history  that  the  inco-ordination  of 
movements  is  the  predominant  factor  in  the  symptomatology  of  chorea. 
Chorea  is  merely  the  expression  of  certain  irritative  disorders,  acting 
more  or  less  profoundly  upon  the  co-ordinating  apparatus. 

The  participation  of  the  cerebrum  in  this  disease  is  demonstrated  by 
the  symptoms  of  irritation,  which  are  observed  on  the  part  of  various 
motor  cranial  nerves,  by  the  disturbance  of  ideas  and  of  speech,  and  by 
the  development  of  psychical  affections.  It  is  also  shown  by  the  appear- 
ance of  chorea  in  apoplexy,  softening  and  tumors  of  the  brain,  and  by 
its  aggravation  after  mental  excitement  (anger,  fear,  etc.)  We  have 
referred  above  to  an  experiment,  in  which  disorders  of  circulation  pro- 
duced in  the  brain  caused  a  greater  violence  of  the  choreic  movements. 
In  patients,  an  exaggerated  effort  of  the  will  suffices  to  bring  into  play 
the  morbid  excitability  of  the  nerve-centres.  The  anatomical  basis  of 
these  facts  is  found  in  the  exudations  observed  by  Meynert,  around  the 
vessels  of  the  brain  and  cord,  and  in  the  gray  matter.  The  theory  of  a 
condition  of  irritation  of  the  centres  of  co-ordination  contained  in  the 
mesocephalon  and  cerebellum,  and  of  its  propagation  to  the  motor  con- 
ductors, is  thus  found  to  be  justified  by  the  positive  intervention  of  the 
brain  in  chorea. 

The  part  played  by  the  cord  in  the  production  of  chorea  is  readily 
vmderstood,  if  we  take  into  consideration  the  important  changes  in  the 
sensory  conductibility  of  the  posterior  columns,  as  shown  by  pathological 
anatomy,  and  confirmed  by  experimentation.  The  exaggerated  excita- 
bility of  the  spinal  system  is  also  manifested  by  the  cutaneous  hj'perajs- 
thesia,  which  is  sometimes  observed  in  chorea,  and  by  the  abnormal 
reactions  to  the  galvanic  current.  Finally,  the  irritation  of  the  cilio- 
spinal  centre  is  expressed  by  the  spasmodic  dilatation  of  the  pupils  in 
severe  attacks  of  chorea  (as  in  the  observation  reported  above). 

We  are  justified  in  concluding,  from  the  preceding  clinical  and  ana- 
tomical facts,  that  in  chorea  minor  the  co-ordinating  apparatus  is  affected 
both  in  its  cerebral  and  spinal  portions.  The  form  of  the  disease  is 
sensibly  modified,  according  as  the  affection  predominates  in  the  one  or 
other  of  these  parts.  In  cases  which  recover,  the  symptoms  of  irritation 
disappear  with  the  cessation  of  the  functional  hypertemia,  which  accom- 
panies the  motor  irritation  and  its  irradiations  to  neighboring  cells 
(associated  movements),  or  with  the  absorption  of  the  slight  exudations 
which  have  formed.  It  is  only  in  very  rare  cases  that  the  changes  in  the 
vascular  walls,  and  in  the  nerve-fibres  and  cells,  terminate  in  secondary 
lesions  and  persistent  disorders  of  some  segment  of  the  apparatus  of  co- 
ordination. 

The  chorea  which  is  manifested  in  articular  rheumatism,  in  inflamma- 
tions of  the  pericardium  or  endocardium,  in  affections  of  the  female 
sexual  organs,  in  intestinal  irritations,  etc.,  is  of  reflex  origin.  It  is  due 
to  a  congenital  exaggeration  of  the  excitability  of  the  apparatus  of  co- 
ordination, the  latter  being  disturbed  in  its  functions  by  the  period  of 
puberty,  by  paychical  excitement,  and   by  constitutional  debility.     Ac- 


DISEASES    OF    THE    NERVOTJS    SYSTEM.  -  123 

cording'  to  Bright,    irritation    originating    in    the    pericardium    may    be 
propagated  to  the  cord  along  the  phrenic  nerve. 

Diagnosis  and  Prognosis. 

In  a  large  number  of  cases,  as  in  children,  and  during  the  period  of 
puberty,  pregnancy  or  the  puerperal  state,  the  symptomatology  is  so  ex- 
pressive that  no  confusion  with  other  morbid  affections  is  possible.  In 
adults,  certain  conditions  are  accompanied  by  clonic  spasms  which  pre- 
sent more  or  less  resemblance  to  chorea,  but  may  be  readily  distinguished 
by  well  determined  symptoms.  Paralysis  agitans  is  recognized  by  its 
preference  for  advanced  age,  by  the  peculiar  gait  of  the  patients,  the 
muscular  rigidity,  and  the  deformity  of  the  hands;  voluntary  acts  are 
not  disturbed,  as  in  chorea,  by  associated  movements,  the  limbs  which  are 
subject  to  tremor  become  more  quiet  when  they  are  supported,  and  finally 
the  disease  not  infrequently  terminates  in  true  paral3'sis.  In  the  facial 
spasms  occurring  in  adults  (convulsive  tic),  the  spasms  are  symmetrical, 
paroxysmal,  and  limited  to  certain  muscles  of  the  face  and  neck.  The 
disease  which  Dubini  has  termed  electrical  chorea  (muscular  twitchings 
and  shocks  affecting  the  entire  body,  occurring  after  pains  in  the  head 
and  back),  and  tetanic  chorea,  are  probably  due  to  acute  diseases  of  the 
brain  and  cord  or  their  meninges,  and  cannot  be  regarded  as  primary 
forms.  The  choreic  movements  which  sometimes  occur  in  certain  cere- 
bral tumors,  are  accompanied  by  other  tumor  symptoms. 

We  should,  therefore,  always  endeavor  to  determine  whether  choreic 
movements  are  due  to  a  primary,  idiopathic  affection  (it  is  more  exact  to 
regard  it  as  a  sympathetic  affection,  from  irritation  of  the  centres  of  co- 
ordination, due  to  chlorosis  or  ana?mia),  whether  they  are  symptomatic  of 
a  cerebral  or  spinal  affection,  or  whether  they  are  reflex  phenomena  oc- 
curring in  the  conditions  to  which  we  have  previously  referred.  We  will 
be  enabled  to  make  this  distinction  in  the  majority  of  cases,  by  an  atten- 
tive observation  of  the  symptoms. 

The  jyt'ognosis  of  chorea  is  usually  favorable,  and  the  large  proportion 
of  cases  recover  completely.  A  fatal  termination  from  exhaustion,  mar- 
asmus, decubitus,  or  inflammatory  complications,  occurs  in  exceptional  in- 
stances. Obstinate  insomnia,  which  debilitates  the  patients,  offers,  ac- 
cording to  Trousseau,  an  unfavorable  prognosis  when  delirium  and  fever 
are  superadded.  When  the  chorea  is  symptomatic,  the  prognosis  depends 
upon  the  primary  affection.  In  ordinary  chorea,  the  symptoms  mend  in 
a  progressive  and  continuous  manner,  until  recovery  is  complete. 

The  morbid  disposition,  which  gives  rise  to  the  disorders  of  co-ordina- 
tion, may  disappear  spontaneously,  as  the  organism  of  the  young  patients 
becomes  more  vigorous,  or  it  may  yield  to  the  remedies  employed  to  re- 
store the  energy  of  the  nervous  system.  If  neither  of  these  events  takes 
place,  experience  teaches  that  relapses  not  infrequently  occur,  and  almost 
always  terminate  in  severe  and  rebellious  forms.  As  a  rule,  relapses  de- 
velop much  more  frequently  in  the  female  sex.  Recent  forms  of  chorea 
may  be  arrested  by  the  development  of  intercurrent  diseases  (acute  exan- 
themata). 

7\-eatmenf. 

Starting  from  the  doctrine  that  the  disease  was  due  to  an  inflamma- 
tory irritation  of  the  spinal  cord,  chorea  has  been  treated  by  antiphlogis- 


124  ^  CLINICAL   TREATISE    ON 

tics  (venesection  or  scarification  along  the  vertebral  column)  and  deriva- 
tives (Rasori  and  Laennec  recommended  tartar  emetic).  At  the  present 
time,  venesection  or  scarification  along  the  vertebral  column  are  only  em- 
ployed in  full-blooded,  vigorous  subjects. 

Among  the  nervines,  iron,  zinc  (valerianate  or  oxide  in  doses  ranging 
as  high  as  a  scruple  daily),  bismuth,  and  nitrate  of  silver,  are  employed 
when  the  patients  are  anremic.  Arsenic  (under  the  form  of  Fov^^ler's  so- 
lution) is  especially  recommended  by  Romberg;  it  is  prescribed  in  doses 
of  three  to  five  drops,  three  times  a  day.  In  two  cases,  I  gave  increasing 
doses  of  Fowler's  solution  up  to  eight  drops  at  a  dose,  and  obtained  rapid 
diminution  of  the  choreic  symptoms,  without  the  appearance  of  any  phe- 
nomena of  poisoning.  According  to  J.  Lewis  Smith  (Med.  Rec,  1872),  sub- 
cutaneous injections  of  Fowler's  solution,  employed  in  the  manner  to 
which  we  have  previously  referred,  are  useful  in  rebellious  forms  of  the 
disease. 

Narcotics  should  only  be  employed  in  very  marked  conditions  of  ex- 
citement. In  obstinate  insomnia,  we  may  prescribe,  in  addition  to  warm 
baths,  hypodermic  injections  of  morphine,  or  doses  of  opium  repeated 
hourly  until  sleep  is  produced.  In  certain  severe  cases.  Trousseau  has  seen 
the  patients  tolerate  enormous  doses  of  this  drug.  Inhalations  of  chloro- 
form have  been  successfully  employed  by  Marsh,  Prevost,  Fuster,  Gery, 
etc.,  especially  when  the  disease  was  attended  with  violent  convulsive 
movements.  I  have  also  seen  good  results  from  chloroform  narcosis,  in 
cases  of  violent  excitability  and  jactitation.  When  the  necessary  precau- 
tions are  adopted  (empty  stomach,  strict  watch  over  pulse  and  respiration, 
frequent  inspiration  of  air  during  the  inhalation),  the  antesthesia  may  be 
repeated  twice  a  day  for  several  days  in  succession,  and  quiet  is  almost 
alvva3's  obtained  in  this  manner. 

According  to  Trousseau  and  Lubelsky,  irrigation  of  the  vertebral  col- 
umn with  sulphuric  ether  is  useful  in  obstinate  cases  which  are  subject  to 
relapses.  The  use  of  strychnine,  which  is  recommended  by  Trousseau 
and  Forget,  has  not  been  attended  with  good  results  in  See's  hands.  At 
all  events,  this  remedy  must  be  given  with  caution,  on  account  of  the 
general  excitability  of  the  patients. 

According  to  Dumont,  bromide  of  potassium  (in  increasing  doses)  pro- 
duces rapid  improvement  in  the  symptoms.  Ogle  extols  the  action  of  the 
tincture  of  Calabar  bean  (five  grammes  of  Calabar  bean  to  thirty-five 
grammes  of  alcohol;  ten  to  twenty  drops  are  given  three  times  a  day  in  a 
little  water).  TurnbuU  has  obtained  excellent  effects  in  six  cases  from 
the  sulphate  of  aniline  (0.05-0.08  three  times  a  day);  Steiner  has  not  ob- 
tained similar  results  from  the  emplo^'ment  of  this  drug.  We  must  men- 
tion, as  a  disagreeable  effect  of  this  remedy  that,  after  its  prolonged  use, 
the  lips,  tongue,  nails  and  even  the  hands  are  colored  blue,  and  the  skin 
assumes  a  sombre  hue.  After  the  administration  of  the  drug  is  suspended 
the  coloration  disappears  in  twenty-four  hours.  Hydrate  of  chloral  also 
gives  good  results. 

Finally,  reference  must  be  made  to  electricity  and  hydrotherapeutics 
in  the  treatment  of  chorea. 

Many  English  physicians  apply  strong  sparks  of  static  electricity  to 
the  vertebral  column  in  cases  of  chorea.  Muscular  faradization  is  em- 
ployed by  Duchenne,  and  cutaneous  faradization  by  Becquerel  and  Bri- 
quet; the  latter  author  administered  chloroform  previously,  on  account 
of  the  cutaneous  hyperesthesia.  From  my  experience  in  a  large  number 
of  observations,  I  give  the  preference  to  the  continuous  current,  a  stabile 


DISEASES    OF    THE    NEEVOUS    SYSTEM.  125 

current  of  moderate  intensity  being  passed  from  the  vertebral  column  to 
the  nerves  of  the  affected  parts  (for  three  to  five  minutes).  I  have  not 
been  able  to  observe,  as  Onimus  asserts,  that  the  direction  of  the  current 
exerts  any  influence  upon  the  final  result.  In  many  cases,  the  muscular 
spasms  improve  very  rapidly;  at  other  times,  on  the  contrary,  several 
weeks  elapse  before  any  good  effects  are  produced. 

Hydrotherapeutic  measures  have  been  long  employed  in  the  following 
manner:  the  patients  are  placed  in  a  warm  half-bath,  and  the  vertebral 
column  is  douched  with  cool  water  falling  in  a  small  jet  from  a  moderate 
height.  A  much  more  soothing  and  invigorating  effect  is  produced  (as  I 
have  shown  in  a  large  number  of  cases)  by  moist  packs  of  the  entire  body, 
employed  until  the  body  is  moderately  warm,  and  followed  by  a  half-bath 
of  23°  C,  which  is  gradually  cooled  to  18°  C,  the  body  being  frequently 
douched  and  rubbed  during  the  entire  procedure.  In  severe  cases,  this 
plan  may  be  practised  morning  and  evening,  and  the  patient  may  then 
take  moderate  exercise  in  the  open  air. 


126  CLINICAL   TREATISE    ON 


CHAPTER  XXXV. 

weiter's  ceamp  (spasm  of  the  hanl»  with  inco-oedination). 

Not  alone  those  spasms  of  the  hand  which  render  writing  impossible, 
but  the  more  or  less  analogous  phenomena  which  present  obstacles  to 
sewing,  knitting,  drawing,  and  performing  upon  the  violin  or  piano,  have 
all  been  collected  under  the  improper  term,  writer's  cramp.  We  shall 
therefore  discuss  those  spasms  which  evidently  result  from  disorders  of 
co-ordination,  and  involve  delicate  and  complex  motor  acts,  under  the  term 
^'spas77i  of  the  hand  with  inco-ordination^''  or  '■'■  artisan^ s  neurosis^ 


Symptomatology. 

The  spasms  of  the  hand  with  inco-ordination,  which  are  manifested  in 
writing,  appear  most  frequently  within  the  territory  of  the  median  nerve 
(spasm  of  the  flexors),  of  the  radial  nerve  (sudden  extension  of  the  fin- 
gers), or,  finally,  of  the  ulnar  nerve  (deviation  of  the  hand  to  the  right 
and  outwards).  The  spasm  in  the  direction  of  the  median  nerve  may  be 
tonic,  in  which  case  the  thumb  and  index-finger  are  curved  inwards  and 
seize  the  pen  convulsively;  at  other  times  the  spasm  is  clonic,  and  then 
these  two  fingers  are  forced  to  perform  a  movement  of  propulsion,  which 
often  causes  the  pen  to  twirl  around  its  own  axis. 

In  the  beginning  of  the  affection,  a  disagreeable  sensation  of  tension 
in  the  hand  is  only  felt  after  the  patient  has  been  writing  for  a  long 
time,  and  hardly  attracts  attention  at  first,  until  the  hand  becomes  more 
and  more  fatigued,  and,  together  with  the  fingers,  soon  becomes  affected 
with  tremor,  which  forces  the  patient  to  rest  frequently  while  writing. 
As  this  difficulty  in  writing  becomes  more  marked,  the  formation  of 
thick  and  fine  strokes  becomes  interfered  with,  and  the  letters  become 
small,  poorly  formed,  and  indistinct.  When  the  attempt  is  made  to  cor- 
rect this  imperfection  by  increasing  the  attention  and  the  efforts  to  handle 
the  pen,  an  increase  in  the  spasms  and  weakness  of  the  hand  is  the  result. 
This  is  soon  followed  by  complete  spasm  of  the  flexors  and  extensors, 
or  by  clonic  spasms  in  certain  muscles  of  the  fingers,  producing  a  pain- 
ful tension,  more  marked  in  the  extensor  muscles  of  the  forearm,  but  in- 
volving even  the  muscles  of  the  shoulder  and  thorax. 

If  we  analyze  in  detail  the  physiological  series  of  acts  concerned  in 
writing,  as  has  been  done  by  Duchenne,  and  especially  by  Zuradelli  (Del 
crampo  degli  scrittori,  Gaz.  Med.  Ital.,  Lombard,  36-42,  1857),  it  will  be 
found  that  this  act  results  from  the  combination  of  delicate  and  complex 
movements,  demanding  an  harmonious  and  precise  co-ordination,  and  an 
alternating  action  of  certain  muscles  of  the  fingers.  The  formation  of 
the  thick  and  fine  strokes,  which  is  carried  on  by  the  thumb  and  first 
two  fingers,  is  performed,  in  its  first  half,  by  the  synergic  extension  of 
the  last,  and  flexion  of  the  first  phalanges   (by  means  of  the  interossei, 


DISEASES    OF   THE    NEEVOÜS    SYSTEM.  127 

lumbricales,  flexor,  opponens  and  extensor  pollicis);  in  the  second  half, 
an  inverse  action  is  produced  by  a  simultaneous  contraction  of  the  deep 
flexor  and  common  extensor  of  the  fingers.  The  propulsion  of  the  hand 
from  left  to  right  along  the  lines,  and  the  movements  of  immersion  and 
drawing  back  of  the  pen,  are  effected  by  contractions  of  the  teres  minor, 
infraspinatus  and  deltoid  (with  the  aid  of  the  flexors). 

It  is  evident,  therefore,  that  in  this  complex  series  of  movements  we 
especially  call  into  requisition  the  small  muscles  which,  in  certain  condi- 
tions of  individual  excitability,  are  readily  affected  with  spasm.  The 
repetition  of  the  latter  will  result  in  progressive  weakness  of  combined 
movements,  and  may  finally  jeopardize  the  power  of  writing.  According 
as  the  movements  which  we  have  enumerated  are  embarrassed  in  different 
degrees  or  perhaps  even  abolished,  various  forms  of  writer's  cramp  will  be 
manifested.  Sometimes  the  formation  of  the  fine  lines  is  markedly  inter- 
fered with,  the  first  and  second  phalanges  forming,  during  flexion,  a  more 
obtuse  angle  than  usual. 

The  muscles  which  are  most  frequently  affected  with  spasm  are  the 
small  muscles  of  the  phalanges  and  those  of  the  thumb.  The  cramp  may 
manifest  itself  under  the  form  of  clonic  contractions  (spasm  with  tremor),  or 
of  tonic  spasm  of  the  flexors,  affecting  chiefly  the  thumb,  which  then  forces 
the  pen  firmly  against  the  paper.  Spasm  of  the  extensors  may  be  tem- 
porarily produced,  and  the  pen  will  then  be  suddenly  removed  from  the 
paper;  this  is,  on  the  whole,  a  very  rare  symptom,  and  may  be  due  to  spasm 
of  the  muscles  which  carry  the  hand  across  the  paper.  In  the  beginning 
of  the  disease  isolated  spasms  are  observed  from  time  to  time,  and  cause 
an  obstacle  to  one  or  the  other  movement  in  writing.  In  general,  the 
spasms  and  functional  disturbances  involve  the  different  muscles  of  the 
fingers  and  thumb,  and,  if  the  work  is  nevertheless  persisted  in,  they  will 
also  affect  the  muscles  of  the  forearm  and  arm. 

Artisan's  cramp  is  not  produced  merely  by  writing.  In  predisposed 
subjects  it  may  manifest  itself  in  the  following  occupations  :  sewing, 
knitting,  drawing,  playing  piano,  violin,  or  harp;  in  engravers,  printers, 
etc.,  whose  work  demands  continuous  activity  in  the  movements  of  the 
fingers  and  hand.  Coarser  movements,  which  involve  the  muscles  of  the 
fingers  and  arms  to  a  less  extent,  do  not  give  rise  to  similar  disturbances. 

Some  patients  suffer  from  neuralgic  pains,  painful  points  along  the 
nerves  of  the  arm,  and  sensibility  to  pressure  and  to  electrical  stimulation 
of  certain  portions  of  the  vertebral  column.  Electrical  exploration  reveals 
perversions  of  the  normal  mode  of  contractions  in  some  forms  of  writer's 
spasm..  The  contraction  upon  closure  at  the  anode  is  produced  in  certain 
nerves  more  quickly  and  strongly  than  the  contraction  upon  closure  at  the 
cathode,  or  the  opening  contractions  at  the  negative  pole  appear  earlier 
than  at  the  positive  pole.  We  may  also  be  able  to  detect  anomalies  in 
the  primary  excitability,  and  an  increase  of  irritation  from  the  action  of 
the  poles.     Eulenburg  (loc.  cit.)  has  also  made  similar  observations. 


Etiology. 

The  most  frequent  cause  of  this  disease  is  the  excessive  labor  to  which 
the  small  muscles  of  the  fingers  are  subjected  in  the  different  pursuits  to 
which  we  have  above  referred.  The  use  of  steel  pens,  on  account  of 
their  rigidity  and  slight  elasticity,  perhaps  favors  the  development  of 
writer's  cramp.    But  this  is  not  the  sole  cause,  since  the  disease  sometimes 


128  CLINICAL    TREATISE    ON 

appears  in  patients  who  have  always  made  use  of  quills.  In  some  cases 
of  clonic  writer's  spasm,  Remak  has  observed  a  chronic  inflammation  of 
the  median  nerve.  This  author  also  states  that  inflammatory  irritation  of 
purely  sensory  nerve-fibres,  such  as  the  superficial  branch  of  the  radial 
nerve,  may  give  rise  to  writer's  cramp,  and  he  has  obtained  recovery  in 
some  of  these  patients  by  the  local  application  of  the  constant  current. 

With  regard  to  the  etiology  of  the  disease,  great  importance  must  be 
attached  to  predisposition.  In  the  patients  whom  I  have  observed,  abnor- 
mal conditions  of  sensibility  of  an  hereditary  nature  were  almost  always 
present.  They  were  of  a  very  excitable  or  timid  disposition,  suffered 
more  or  less  from  nervous  palpitation,  from  spasms  in  various  parts  of  the 
body,  or  from  hysterical  symptoms.  Among  twenty-five  cases  of  writer's 
cramp  collected  by  Fritz,  seven  suffered  from  strabismus,  choreic  move- 
ments, spasm  of  deglutition,  etc.  The  dynamic  and  traumatic  influences, 
which  have  been  regarded  as  exciting  causes,  constitute  the  exceptions. 

Writer's  cramp  is  chiefly  due  to  the  morbid  susceptibility  of  certain 
individuals.  The  irritation  produced  by  manual  effort  proceeds  from  the 
sensory  muscular  fibres  (Fritz),  and,  in  addition,  from  the  nerves  which 
are  distributed  to  the  articulations  of  the  fingers  and  hand,  and  causes,  by 
reflex  action,  a  disturbance  in  the  co-ordinated  action  of  the  muscles. 
Then  follows  a  more  and  more  marked  disorder  in  the  regular  and  asso- 
ciated play  of  the  muscular  actions,  a  spasmodic  perturbation  of  their 
function,  and  marked  exhaustion  of  the  co-ordinating  apparatus,  which 
only  lapses  into  this  condition  of  weakness  from  the  over-excitement  fol- 
lowing frequent  spasms.  Writer's  cramp  may  be  artificially  produced,  as 
I  have  shown  by  experiments  upon  myself  and  upon  various  patients,  by 
means  of  stimulation  with  the  faradic  current.  If  a  strong  current  is 
applied  to  the  first  two  interossei  and  to  the  thenar  eminence  simulta- 
neously, while  the  hand  is  occupied  in  writing,  a  tonic  spasm  will  be  pro- 
duced in  the  extensors  of  the  thumb  and  index-finger,  especially  during 
the  formation  of  the  fine  lines.  The  letters  become  distorted,  the  pen 
rotates  upon  its  own  axis,  and  finally  leaves  the  paper.  If  the  current  is 
brought  to  bear  upon  the  dorsal  surface  of  the  forearm,  over  the  motor 
points  of  the  extensor  indicis  and  of  the  long  extensor  of  the  thumb,  the 
pen  will  be  drawn  away,  and  if  the  current  is  continued  for  a  certain 
length  of  time,  the  fingers  are  seized  with  tremor  and  persistent  spasm. 
If  we  employ  two  induction  coils  of  different  intensities  we  can  produce 
spasms  of  unequal  force  in  the  hand. 

The  central  situation  of  these  disorders  of  co-ordination  only  extends 
over  a  small  space,  as  a  rule,  for  we  have  previously  shown  that  the  inco- 
ordination rarely  affects  other  groups  of  movements.  In  this  respect 
writer's  spasm  is  analogous  to  the  disorders  in  the  co-ordination  of  speech 
which  constitute  stuttering,  and  we  may  term  the  former  affection,  stut- 
tering of  the  hand  or  of  writing.  Nevertheless,  in  writer's  cramp,  the 
symmetrical  portion  of  the  nerve-centres,  on  the  opposite  side,  shows  a 
tendency  to  become  involved,  for,  if  the  patient  learns  to  write  with  the 
other  hand,  the  latter  soon  becomes  affected  with  the  spasm. 


Diagnosis  and  Prognosis. 

Writer's  cramp  may  be  mistaken  for  analogous  conditions  which  have 
been  produced  by  lesions  of  the  brain  and  spinal  cord.  In  unilateral 
ataxia,  similar  phenomena  may  appear  (I  have  seen  two  examples)  among 


I 


DISEASES    OF   THE   NEKVOUS   SYSTEM.  129 

the  first  symptoms  of  the  disease.  But  these  phenomena  are  almost  al- 
ways combined  with  sensory  disturbances  (numbness,  anaesthesia,  neural- 
gia) in  the  fingers  and  arm,  sometimes  also  in  other  parts  of  the  body, 
and  even  in  the  lower  limbs.  In  addition,  temporary  muscular  spasms, 
sexual  excitement,  and  a  marked  increase  in  the  galvanic  reactions,  are 
also  observed.  Zuradelli  has  noted  cases  of  writer's  cramp,  attended  with 
hyperaesthesia  or  anaesthesia,  loss  of  sensibility  to  contact  or  pain,  or  of 
muscular  sensibility.  These  symptoms  must  be  referred  to  a  central 
cause,  as  they  are  not  noticed  in  ordinary  cases. 

In  cerebral  diseases  the  associated  movements  of  the  fingers  or  hands 
may  be  disturbed  by  spasms  and  paresis,  simulating  writer's  cramp.  But 
we  will  then  find  uncertainty  and  weakness,  even  in  performing  coarse 
movements,  combined  with  sensory  disturbances  and  paresis  in  the  lower 
extremity  on  the  same  side,  and  later  in  the  territory  of  the  cranial 
nerves. 

In  hysteria,  progressive  muscular  atrophy,  and  lead  paralysis,  a  symp- 
tomatic writer's  cramp  may  occur  after  exertion,  but  the  other  character- 
istic signs  will  clear  up  the  nature  of  the  disease. 

The  trembling  movements  which  characterize  certain  forms  of  writer's 
cramp  are  distinguished  from  other  forms  of  tremor  by  the  fact  that  the 
latter  are  also  manifested  in  movements  which  do  not  require  co-ordinated 
action,  and  that  they  pursue  a  much  more  continuous  course. 

The  proffnosis  in  spasm  of  the  hand  with  inco-ordination  is  so  much 
the  more  unfavorable,  the  more  severe  and  extensive  the  disease  has  be- 
come. The  light  forms,  which  sometimes  occur  with  symptoms  of  anae- 
mia, dyspepsia,  and  after  prolonged  exertion,  may  be  arrested  by  method- 
ical tonic  treatment  and  by  abstinence  from  all  manual  occupations  which 
demand  considerable  effort.  If  the  necessary  measures  be  adopted,  evea 
more  advanced  forms  may  remain  stationary  for  several  years,  or  may,, 
perhaps,  present  an  appreciable  degree  of  improvement,  although  this  is 
soon  lost  if  these  precautions  are  dispensed  with.  Some  of  these  cases, 
are,  perhaps,  susceptible  of  recovery  under  appropriate  treatment  and 
continuous  care. 

Severe  and  extensive  forms  may  improve  somewhat,  but  offer  no  hope 
of  recovery. 

Treatment. 

Writer's  cramp  was  formerly  treated  with  narcotics,  tonics,  stimulants, 
nervines,  and  blisters,  but  the  complete  inefficacy  of  these  measures  ha.'« 
long  been  recognized.  Strychnine,  which  has  been  recently  employed  by 
some  physicians,  is  too  dangerous,  even  in  small  doses,  to  be  employed  a.** 
a  mere  adjuvant.  Surgical  treatment  (subcutaneous  muscular  section) 
was  successful  in  a  case  reported  by  Stromeyer,  in  which  the  spasm  wa« 
limited  to  the  long  flexor  of  the  thumb.  In  other  cases,  however,  which 
were  operated  upon  by  Dieffenbach  and  Langenbeck,  it  produced  no  ben- 
efit or  only  temporary  relief.  The  mechanical  contrivances  invented  by 
Gerdy,  Cazenave,  and  others  do  not  produce  any  permanent  advantage 
Massage  is  followed  by  better  results. 

Methodical  hydrotherapeutics  (frictions,  packs  of  short  duration,  fol- 
lowed by  half  baths,  dorsal  affusions,  gentle  douches  to  the  lumbar  region 
and  neck),  a  prolonged  trip  to  the  country,  and  sea-baths,  have  a  favor- 
able influence  in  counteracting  the  nervous  excitability  of  the  patients 
and  in  moderating  the  spasms. 
Vol.  li.— 9 


130  CLIinCAL   TREATISE   ON 

Electricity  also  gives  good  results  in  this  affection ;  but  the  number  of 
recoveries  always  remains  very  small,  compared  with  those  cases  which 
are  merely  improved.  Duchenne  and  M.  Meyer  have  seen  good  effects 
from  galvanization  of  the  affected  muscles.  The  constant  current  is  pref- 
erably employed,  on  account  of  its  slighter  tension.  A  stabile  current 
of  moderate  intensity  is  passed  through  the  upper  part  of  the  vertebral 
column  or  from  the  spine  to  the  brachial  plexus,  and  then  to  the  affected 
nerves  and  muscles,  each  sitting  lasting  from  three  to  five  minutes.  In 
some  cases  I  have  obtained  great  benefit  by  combining  galvanization 
with  a  few  sittings  of  localized  faradization  to  the  paretic  muscles,  or  with 
mild  hydrotherapeutic  measures. 

But  whatever  the  plan  of  treatment  adopted,  it  is  absolutely  necessary 
that  the  patient  abstain  completely,  for  at  least  six  months  or  a  year,  from 
the  work  in  which  he  had  been  previously  engaged,  and  it  can  only  be  re- 
sumed slowly  and  gradually.  It  is  well  to  premise  the  return  to  work  by 
carefully  graduated  gymnastics  of  the  articulations  of  the  fingers  and 
hands,  and  by  rhythmical  exercises  of  the  brachial  muscles. 


DISEASES    OF   THE   NERVOUS    SYSTEM.  131 


CHAPTER  XXXVI. 

STUTTERING. 


I 


The  consideration  of  this  affection  naturally  follows  that  of  writer's 
spasm,  while,  on  the  other  hand,  certain  undeniable  characteristics  point 
very  clearly  to  its  affinities  with  chorea. 


Symptomatology. 

Stuttering  develops  between  the  ages  of  five  to  ten  years,  or  a  little 
later,  and  first  becomes  evident  by  the  difficulty  experienced  in  pronoun- 
cing certain  syllables,  and  by  the  repeated  efforts  and  interruptions  which 
accompany  the  pronunciation  of  Unguals,  labials,  and  gutturals.  If  stut- 
tering manifests  itself  in  the  first  years  of  childhood,  it  becomes  an  ob- 
stacle to  intellectual  development,  inasmuch  as  the  child  is  supposed  to 
be  weak,  and  all  mental  exertion  is  carefully  avoided.  We  therefore  find 
that  the  stuttering,  which  was  expected  to  disappear  as  the  child  devel- 
oped, increases  with  years  and  becomes  more  obstinate. 

At  a  later  period,  when  the  stuttering  is  more  marked,  the  face 
becomes  affected,  while  speaking,  with  spasms  and  contortions,  corre- 
sponding to  the  efforts  of  will  which  the  patient  makes;  the  tongue  is 
moved  upwards  and  downwards  in  a  convulsive  manner,  or  is  forced  be- 
tween the  teeth;  the  head  is  turned  to  one  side;  the  eyes  roll  in  their 
orbits  with  an  expression  of  anguish;  the  saliva  is  expectorated  in  jets 
by  the  convulsive  contractions  of  the  labial  commissures;  the  muscles  of 
the  jaw  and  lip  become  rigid  at  times,  during  which  the  expiration  re- 
mains suspended;  the  face  is  turgid  and  has  an  anxious  expression. 
After  numerous  expiratory  efforts  and  repeated  movements  of  the  tongue, 
the  lips  finally  open,  and  the  pseudo-suffocatory  paroxysm  is  terminated 
by  the  utterance  of  a  sound.  In  severe  cases  this  scene  is  soon  renewed; 
whenever  the  patient  wishes  to  express  an  idea,  the  same  insubordination 
of  the  organs  of  speech  makes  its  appearance.  In  this  miserable  situa- 
tion he  is  isolated  from  the  society  of  his  fellows,  and  the  exercise  of  his 
profession  or  even  life  itself  becomes  embittered  thereby.  Singing  and 
declamation  are  performed  perfectly  by  the  majority  of  these  patients; 
it  is  only  in  very  advanced  cases  that  the  infirmity  becomes  apparent 
even  when  they  recite  poetry.  In  whispering,  or  even  in  speaking  in  a 
low  tone  of  voice,  stutterers  can  pronounce  words  with  surprising  facility. 
Under  the  influence  of  embarrassment  or  depressing  moral  conditions, 
speech  is  produced  in  the  form  of  fragments  of  words;  anger,  quarrels, 
or  an  animated  conversation  with  friends,  facilitates  the  flow  of  speech. 

The  pronunciation  of  vowels,  which  is  effected  by  intonation,  i.  e.,  by 
the  intervention  of  the  larynx  and  glottis,  does  not  present  any  especial 
difficulty  to  the  majority  of  stutterers. 

Vocal  stuttering  (stuttering  of  the  initial  vowels)  constitutes  a  severe 


132  CLINICAL   TKEATISE    ON 

form  of  the  disease.  The  pronunciation  of  consonants  plays  a  much 
greater  part  among  the  pathological  phenomena  of  stuttering.  In  the 
pronunciation  of  consonants  in  the  normal  condition  there  is  no  change,  or 
merely  a  slight  modification  in  the  relations  of  the  larynx  and  hyoid  bone; 
but  the  expired  air,  which  is  forced  through  the  glottis  and  escapes 
through  the  buccal  cavity,  must  overcome  certain  obstructions  or  con- 
strictions in  its  passage,  thus  giving  rise  to  the  various  consonants.  Ac- 
cording to  the  point  betveeen  the  larynx  and  buccal  orifice  at  which  this 
occlusion  or  narrowing  occurs,  Bruecke  (in  his  classical  work  upon 
phonation)  divides  the  consonants  into  three  classes,  each  corresponding 
to  a  certain  region  of  articulation,  and  these  again  are  subdivided  into 
two  series.  Those  isolated  sounds,  whose  pronunciation  is  accompanied 
by  manifest  vibrations  of  the  walls  of  the  thorax  and  of  the  larynx,  are 
called  "  resonant,"  and  those  which  are  unaccompanied  by  such  vibra- 
tions are  called  "non-resonant." 

In  order  to  obtain  a  practical  survey  of  the  defects  of  speech,  it  is  ad- 
visable to  recognize  three  centres  for  the  production  of  sounds,  viz.,  the 
anterior,  middle,  and  posterior.  The  anterior  centre,  or  space  in  which 
Bruecke's  first  group  of  consonants  is  formed,  is  narrowed  or  closed  by 
the  rapid  opening  and  closure  of  the  upper  and  lower  lips,  or  of  the  lower 
lip  and  incisor  teeth  ;  the  consonants  p,  b,  f,  v,  m,  are  produced  in  this 
manner. 

In  the  middle  space,  corresponding  to  the  formatien  of  Bruecke's  sec- 
ond group,  the  occlusion  or  narrowing  is  produced  by  means  of  the 
anterior  part  of  the  tongue  and  upper  incisors,  or  the  anterior  part  of  the 
vault  of  the  palate  ;  t,  d,  I,  n,  s,  are  thus  formed.  The  posterior  space  in 
which  the  consonants  of  the  third  group  originate  is  closed  by  means  of 
the  posterior  halves  of  the  tongue  and  palatine  vault  ;  k,  g,  ch,  j,  are 
here  formed.  The  letter  ?•  belongs  to  all  three  groups,  being  either  a 
labial,  lingual,  or  guttural  (more  properly,  a  uvular).  Certain  languages, 
such  as  the  Chinese,  do  not  possess  an  r,  and  it  is  then  usually  replaced 

by/. 

This  sketch  of  the  physiology  of  speech  furnishes  us  with  the  basis  of 
several  divisions  in  stuttering.  Thus  the  condition  in  which  the  sounds 
produced  in  the  anterior  space  are  combined  with  convulsive,  involuntary 
movements  of  the  lips  and  anterior  parts  of  the  tongue,  has  been  called 
by  Colombat  labio-choreic  stuttering  (on  account  of  its  analogies  with 
chorea).  The  variety  in  which  the  emission  of  sounds,  produced  in  the 
posterior,  and  partly  in  the  middle  space,  is  attended  with  a  certain  de- 
gree of  rigidity  in  the  pharynx  and  larynx,  was  called  gutturo-tetanic 
stuttering.  As  a  rule,  both  these  forms  are  combined,  to  the  great  dis- 
tress of  the  patient  as  well  as  of  his  physician. 


Etiologif. 

The  real  pathogenic  cause  of  this  affection  consists  of  an  hereditary  mor- 
bid excitability,  which  affects  by  preference  the  organs  of  language.  Chil- 
dren suffering  from  this  disorder  are  usually  of  a  delicate,  lively,  and  very 
excitable  nature,  in  whom  a  temporary  and  sudden  cause  of  irritation 
(frig-ht,  anger,  traumatic  causes)  will  suffice  to  produce  stuttering.  In 
very  rare  cases  the  affection  is  hereditary.  Thus,  I  had  under  observa- 
tion, at  one  time,  a  girl,  ten  years  of  age,  affected  with  stuttering,  whose 
father  was  similarly  affected,  and  whose  grandfather  had  stuttered  until 


DISEASES    OF   THE    NERVOUS    SYSTEM.  133 

the  age  of  forty,  at  which  time  the  infirmity  disappeared.  The  largest 
number  of  cases  occur  in  the  male  sex  within  the  first  twenty  years  of 
life. 

According  to  Chervin,  from  the  years  1852  to  18G2,  six  thousand  seven 
hundred  and  sevent^'-three  conscripts  in  France  were  declared  unfit  for 
service  on  account  of  stuttering. 

Anjemia,  chlorosis,  and  the  weakness  due  to  masturbation,  favor  the 
development  of  stuttering  in  predisposed  subjects.  It  may  also  appear 
as  a  concomitant  symptom  in  other  disorders  of  co-ordination.  T  was  ac- 
quainted with  an  officer  who  was  obliged  to  retire  from  service  because 
he  became  affected  with  stuttering,  during  the  course  of  locomotor  ataxia, 
and  was  rendered  incapable  of  giving  commands  (spinal  stuttering). 

Among  the  cases  of  writer's  camp  collected  by  Fritz,  stuttering  co- 
existed in  several  instances. 

Our  views  concerning  the  nature  of  stuttering  are  clearer  to-day  than 
in  the  time  of  Colombat,  who  attributed  it  to  a  perversion  of  cerebral 
irradiation  and  to  overstimulation  of  the  muscles  of  language.  As  we 
have  shown  above,  in  the  remarks  on  the  formation  of  speech,  the  pro- 
nunciation of  consonants  depends  chiefly  upon  the  point  at  which  the 
expired  air  meets  with  an  occlusion  or  narrowing  of  the  passages,  l)efore 
escaping  through  the  buccal  orifice.  The  more  the  different  sounds,  which 
must  be  uttered,  belong  to  distinct  groups,  the  more  rapidly  must  the  ac- 
tion of  the  corresponding  organs  succeed  one  another,  the  greater  must  be 
the  certainty  and  precision  in  the  modification  of  the  relations  between 
the  various  parts  of  the  apparatus,  and  the  greater  also  is  the  difficulty 
experienced  by  the  stutterers  in  producing  regular  and  harmonious  com- 
binations of  sounds. 

Stuttering  is  therefore  a  disorder  of  co-ordination  concerned  in  the 
emission  of  sounds,  and,  as  in  writer's  cramp,  is  similarly  circumscribed. 
The  cause  of  stuttering  is  a  congenital  weakness  of  the  apparatus  of 
respiration  and  phonation,  situated  in  the  medulla  oblongata.  This  ap- 
paratus, which  has  been  affected  since  childhood  by  some  psychical 
shock,  does  not  recover  its  proper  tone,  and  responds,  therefore,  to  the 
mere  impulse  of  the  will  by  inco-ordinated  movements.  The  stimulation 
is  irradiated  to  the  adjacent  nerve  nuclei,  and  thus  gives  rise  to  concom- 
itant spasmodic  movements  of  the  muscles  of  the  face,  eyes,  tongue, 
and  even  of  the  neck.  Colombat  had  also  called  attention  to  the  irregu- 
lar, interrupted,  and  rapid  breathing  occurring  in  stutterers. 

In  consequence  of  the  habitually  short,  irregular  respirations,  and 
under  the  influence  of  mental  excitement,  a  large  portion  of  the  air  con- 
tained in  the  thorax  is  lost  before  it  can  be  employed  in  the  formation  of 
words.  With  increase  of  the  anxiety  and  embarrassment,  the  disorders 
of  co-ordination  become  intensified.  The  stutterers  endeavor  to  control 
the  disturbances  in  expiration  by  contracting  their  abdominal  muscles.  If 
the  patients  hold  their  breath  and,  at  the  same  time,  contract  the  abdomi- 
nal muscles,  an  occlusion  of  the  larynx  will  result  (as  Czermak  has  shown 
by  means  of  the  laryngoscope)  from  juxtaposition  of  the  arytenoid  carti- 
lages and  of  the  processus  vocales,  until  the  vocal  cords  are  brought  into 
contact  with  one  another,  and  the  epiglottis,  forming  a  convexity  inter- 
nally, is  applied  to  the  glottis  and  completes  the  occlusion. 

The  stimulation  is  also  propagated  along  the  pneumogastric  nerves, 
and  is  manifested  in  the  constrictors  of  the  pharynx  which  it  innervates, 
in  the  palato-glossus,  and  partly  in  the  thyro-hyoid  muscles.  The  con- 
traction of  these  muscles  causes  the  tongue  to  be  applied  to  the  roof  of 


134  CLINICAL    TREATISE    ON 

the  mouth,  the  pharynx  is  narrowed  and  fixed,  the  communication  of  the 
mouth  with  the  nasal  fossae  is  partly  interfered  with,  and  the  expired  air 
is  therefore  unable  to  escape.  The  expired  air  only  escapes  after  re- 
peated efforts  and  after  elevating  the  epiglottis  ;  or,  under  the  influ- 
ence of  the  want  of  air,  the  glottis  enlarges,  and  the  fauces,  which 
were  previously  narrowed,  relax.  The  dyspnoeic  phenomena  then  cease; 
the  frequent  repetition  of  such  scenes  increases  the  disorders  of  co-ordina- 
tion to  such  an  extent  that  even  rational  therapeutic  measures  are  unable 
to  re-establish  harmony  between  respiration  and  the  other  muscular  move- 
ments, and  to  direct  co-ordination,  by  the  aid  of  the  will,  into  proper 
paths. 

Diagnosis  and  Prognosis. 

Stuttering  is  most  frequently  mistaken  for  stammering.  The  latter 
consists  of  a  difficulty  in  performing  the  movements  requisite  for  the  ar- 
ticulation of  certain  consonants,  phonation  remaining  intact.  It  is  never 
accompanied  by  spasmodic  or  congestive  phenomena,  nor  by  difficulty 
in  respiration.  The  stuttering  which  occurs  in  cerebral  diseases  may  be 
due  to  motor  disturbances  within  the  territory  of  the  hypoglossus,  or  it 
may  be  of  an  aphasic  nature.  The  stuttering  observed  in  cerebral  tu- 
mors and  facial  paralysis  (especially  double)  consists  of  a  difficulty  in  the 
pronunciation  of  labials,  due  to  motor  paralysis  of  the  lips  or  tongue. 

All  these  disturbances  are  wrongly  classified,  by  certain  authors,  under 
the  term  stuttering.  They  should  be  termed  alalia,  as  they  have  nothing 
in  common  with  the  disorders  of  co-ordination.  Among  the  latter  we 
must  also  place  the  special  form  of  stuttering  which  sometimes  develops 
in  ataxia.  All  the  other  so-called  varieties  of  stuttering  (constitutional, 
nervous,  psychical,  etc.)  are  caused,  as  we  have  stated  above,  by  a  con- 
genital weakness  of  the  apparatus  presiding  over  the  co-ordination  of 
speech,  and  are  consequently  not  entitled  to  be  regarded  as  distinct  va- 
rieties. 

The  pj'ogtiosis  is  not  unfavorable  in  young  subjects  who  enjoy  good 
health,  apart  from  their  nervous  excitability.  The  slight  forms  often  dis- 
appear spontaneously  at  a  more  advanced  age.  Severe  and  chronic  types 
are  so  much  the  more  rebellious  according  as  vocal  stuttering  is  more 
pronounced,  and  as  the  choreic  movements  and  dyspnoeic  phenomena  are 
manifested  to  a  greater  extent.  All  other  things  being  equal,  young 
people,  who  have  already  attained  a  certain  age,  present  better  chances  of 
recovery  than  undeveloped  children.  Heredity  renders  the  prognosis  much 
more  unfavorable.  Relapses  not  infrequently  occur  after  recovery  has 
apparently  taken  place. 

Treatment. 

The  labial  gymnastics  first  employed  by  Mrs.  Leigh,  and  perfected  by 
Malbouche,  and  the  constant  application  of  the  tip  of  the  tongue  to  the 
roof  of  the  mouth,  are  insufficient  as  a  means  of  treatment.  Neither  have 
I  observed  any  better  effects  from  the  long-continued  application  of  con- 
stant and  induced  currents  (to  the  larynx,  hypoglossal  nerve,  or  passed 
through  the  head). 

The  rhythmical  method  was  first  instituted  by  Colombat,  and  then  per- 
fected by  Klenke  and  others.  I  have  employed  this  plan  successfully  in 
a  large  number  of  cases.     The  chief  end  in  view  is  to  regulate  the  precipi- 


I 


DISEASES    OF   THE    NERVOUS    SYSTEM.  135 

täte,  irregular  form  of  respiration,  which  occurs  in  the  majority  of  stutterers. 
In  order  to  become  habituated  to  a  certain  rhythm,  the  patient  should  for 
a  long  time  keep  the  eyes  fixed  upon  the  baton  with  which  the  time  is 
kept,  and  should  endeavor  to  regulate,  in  this  manner,  the  movements  of 
inspiration  and  expiration.  The  interval  between  these  two  periods  should 
be  made  longer  and  shorter  at  different  times,  the  teacher  alternately 
beating  time  more  rapidly  or  more  slowly,  sometimes  accelerating,  some- 
times retarding  the  respirations.  In  patients  who  are  able  to  sing,  it  is 
well  to  combine  the  respiratory  gymnastics  with  "  crescendo  "  and  "  de- 
crescendo  "  exercises  on  the  scales,  the  notes  being  sustained  as  long  as 
possible. 

With  regard  to  the  correction  of  speech  itself,  it  is  better,  in  my  opin- 
ion, to  direct  the  patient  for  a  long  time  to  speak  in  syllables,  in  four- 
quarters  time,  and  in  a  not  too  loud  tone  of  voice.  The  physician  should 
always  beat  the  time  himself.  The  latter  act  is  merely  a  regulator  which 
prevents  the  precipitation  of  speech,  and  forces  the  patient  to  carefully 
watch  the  succession  of  words. 

Before  the  patient  begins  to  speak  he  should  take  a  few  deep  inspira- 
tions, and  then  pronounce  the  words  according  to  a  regular  rhythm, 
accompanying  himself  with  movements  of  the  hand.  Each  phrase  should 
be  scanned  like  a  word  of  several  syllables,  slowly  and  with  a  distinct  in- 
tonation, and  each  syllable  should  have  an  equal  duration.  At  each 
punctuation  in  the  course  of  a  phrase,  the  patient  takes  a  fresh  inspiration, 
but  without  interrupting  the  rhythm  of  the  pronunciation.  In  addition, 
it  is  necessary  to  carefully  watch  any  vicious  intonations  made  by  the 
patient,  and  when  the  tongue  is  protruded  too  forcibly,  or  when  it  is  kept 
too  long  upon  the  floor  of  the  mouth,  the  patient's  attention  must  be 
called  to  the  fact,  and  he  should  endeavor  to  correct  it. 

In  order  to  prevent  a  relapse  it  is  necessary  to  continue  the  gymnas- 
tics (for  six  months,  a  year,  or  even  more)  until  the  patient  habitually 
speaks  correctly.  The  education  of  stutterers  is  best  accomplished  in 
special  institutions;  but  we  can  often  succeed  in  private  practice,  by  teach- 
ing the  principles  of  the  method  to  the  relatives  of  the  patient. 


CLASS   VII. 


TOXIC  NEIJROSES-POST-FEBRILE  NERVOUS  DISORDERS-ANi:- 
MIC  AND  REFLEX  PARALYSIS. 


CHAPTER  XXXVII. 

TOXIC   NEUROSES. 

a.  Saturnine  Nervous  Affections. 

Among  the  metallic  preparations,  lead  and  its  combinations  deserve 
especial  attention  on  account  of  the  frequency  and  severity  of  its  effects 
upon  the  nervous  and  muscular  systems.  Lead  may  enter  the  organism 
through  different  channels,  most  frequently  through  the  intestinal  tract, 
and  less  often  through  the  other  mucous  membranes  (cases  reported  by  M. 
Meyer,  Erdmann,  Moeller,  Geenen,  etc.,  of  lead-poisoning  from  the  use  of 
snuff  containing  lead;  Sabatier's  observation,  in  which  lead  colic  and 
arthralgia  vpere  due  to  the  prolonged  application  of  the  acetate  of  lead  to 
the  eyes,  in  a  case  of  blepharophthalmia).  Carbonate  of  lead  may  also  be 
introduced  through  the  lungs,  as  I  have  observed  in  rabbits,  and  in  work- 
ingmen  pursuing  various  trades  (Beobachtungen  ueber  Bleieinwirkung 
auf  den  Thier-Koerper,  Zeitschr.  f.  prak.  Heilk.,  48-51,  1865). 

In  one  factory,  in  which  powdered  glass,  containing  lead,  was  used  in 
the  construction  of  telegraphic  apparatus,  Archambault  found  sixteen 
females  and  three  males  suffering  from  lead  affections.  Finally,  lead  may 
be  introduced  into  the  system  through  the  intact  skin,  as  has  been  proven 
by  the  observations  of  Schottin  (poisoning  from  the  use  of  plates  of  lead 
in  order  to  dye  the  hair;  at  the  autopsy  a  gelatinous  foyer  of  softening, 
containing  lead,  was  found  at  the  base  of  the  left  middle  lobe),  and  by 
the  cases  reported  by  Eulenburg,  Spoerer,  etc.  I  have  also  seen  manifest 
symptoms  of  lead-poisoning  (arthralgias,  tremor,  muscular  weakness, 
confusion  of  ideas  and  of  speech)  caused  by  the  prolonged  use  of  rouge 
containing  lead. 

The  susceptibility  to  the  toxic  action  of  lead  varies  greatly  according 
to  the  individuals.  I  have  noticed  the  development  of  well-marked 
paralyses  of  the  limbs  without  the  previous  existence  of  colic,  neuralgia, 
or  tremor.  At  other  times  we  may  note  repeated  attacks  of  colic,  men- 
strual disorders  in  female  type-setters,  profound  anaemia  with  cardiac 
bruit,  frequent  abortions,  or  delivery  of  still-born  children,  although  these 


138  CLINICAL   TEEATISE   ON" 

phenomena  are  not  followed  by  symptoms  of  paralysis.  Individuals 
who  have  passed  through  several  attacks  of  colic,  experience  weakness 
in  the  limbs,  and  their  muscular  power  often  diminishes  to  such  an  extent 
that  they  are  unable  to  do  heavy  work,  although  they  do  not  present  real 
paralysis.  In  two  cases  of  this  kind,  attended  with  polyuria,  I  found 
the  urine  markedly  albuminous.  Some  authors  have  seen  these  symptoms 
terminate  in  nephritis.  When  arthralgia  occurs  after  violent  colic,  and  is 
accompanied  by  delirium,  even  though  it  is  merely  temporary,  the  patient 
is  threatened  with  an  eclamptic  attack.  When  there  is  an  hereditary 
morbid  disposition  to  central  affections,  the  absorption  of  lead  may  have 
a  still  more  disastrous  effect  upon  the  nervous  system.  Duchenne  (Gaz. 
Med.  de  Paris,  1863)  has  published  the  case  of  a  grinder  of  lenses,  work- 
ing in  lead,  whose  father  and  brother  had  died  of  epilepsy,  and  who,  after 
suffering  from  constipation,  cephalalgia,  and  a  blue  line  upon  the  gums, 
was  attacked  with  lead  eclampsia  followed  by  meningitis.  This  diagnosis 
was  confirmed  upon  autopsy.  Orfila,  Meurer,  and  Devergie  have  deter- 
mined the  presence  of  lead  in  the  brain  in  patients  who  had  died  of 
saturnine  affections.  According  to  the  experimental  investigations  re- 
cently undertaken  by  Heubel  upon  dogs  (Pathogen,  u.  Sympt.  d.  chron. 
Bleivergiftung,  Berlin,  1871),  the  lead  is  found  in  much  larger  quantities 
in  the  brain  and  spinal  cord  than  in  the  liver  and  kidneys.  According  to 
Heubel's  experiments,  and  contrary  to  the  results  previously  obtained  by 
Gusserow  (Virch.  Arch,,  XXI.  Bd.),  the  muscles  contain  less  lead  than 
the  central  nervous  system. 

Gueneau  de  Mussy  and  Lemaire  have  reported  (Gaz.  des.  Hop.,  juillet, 
1863)  the  case  of  a  painter,  agt.  thirty  years,  who  died  in  convulsions  after 
having  had  several  attacks  of  colic  and  delirium.  At  the  autopsy  a  large 
haemorrhage,  communicating  with  the  fourth  ventricle,  was  found  in  the 
brain;  the  heart  and  lungs  presented  a  normal  appearance.  When  cere- 
bral symptoms,  associated  with  paralysis,  occur  in  a  worker  in  lead,  we  are 
frequently  justified  in  attributing  the  cerebral  phenomena  to  lead-poison- 
ing. Duchenne  mentions  the  history  of  a  painter  who  was  seized,  after 
several  attacks  of  colic,  with  a  hemiplegia  which  was  regarded  as  satur- 
nine, until  its  central  origin  was  discovered,  by  noticing  that  the  electro- 
muscular  contractility  and  sensibility  were  normal.  At  the  autopsy  an 
abundant  haemorrhage  was  found  in  the  cerebral  lobes.  I  have  also  pub- 
lished the  case  of  a  painter  (Electrotherapie,  2d  Edit,,  Observ,,  32)  who 
presented,  in  addition  to  coloration  of  the  gums  and  anaemia,  a  right 
hemiplegia,  which  was  looked  upon  as  saturnine  until  electrical  explora- 
tion revealed  the  cerebral  character  of  the  disease.  At  the  autopsy  a  hae- 
morrhage was  found  in  the  external  portion  of  the  left  corpus  striatum 
and  lenticular  nucleus;  the  arteries  at  the  base  were  thickened. 

Saturnine  eclampsia  was  attributed  by  Traube  (Med.  Centralzeit., 
1861)  and  Rosenstein  (Schuchardt's  Zeitschr.,  1867)  to  capillary  cerebral 
anaemia,  caused  by  cerebral  oedema.  Heubel  has  succeeded  in  demon- 
strating the  an£emia  and  increased  proportion  of  water  in  the  cerebral 
substance.  The  lead  albuminuria  and  granular  atrophy  of  the  kidneys, 
observed  by  Ollivier  and  Lancereaux  (Union  Med.,  1864),  were  not  no- 
ticed by  Rosenstein  and  Heubel,  I  have  seen  a  case  of  lead  encephalo- 
pathy in  the  Vienna  General  Hospital,  which  was  interesting  on  account  of 
its  favorable  termination.  The  patient  was  a  painter,  twenty-four  years  of 
age,  who  was  suddenly  seized,  after  six  attacks  of  lead  colic,  with  convul- 
sions in  the  face  and  limbs,  vomiting,  loss  of  consciousness,  and  retardation 
of  the  pulse.     All  the  threatening  symptoms  disappeared  in  a  few  days 


DISEASES    OF   THE    NERVOUS    SYSTEM.  139 

after  the  application  of  leeches  to  the  temples,  cold  compresses  to  the 
head,  and  the  administration  of  intestinal  derivatives.  We  may  finally 
refer  to  saturnine  amaurosis,  occurring  in  man,  and  also  observed  by  Ro- 
senstein in  dogs  that  have  been  poisoned  with  lead,  Meyer  has  pub- 
lished (Union  Med.,  18G'8)  the  case  of  a  bleacher  of  laces,  who  suffered 
from  headache,  convulsions,  and  amblyopia,  and  in  whom  the  ophthalmo- 
scope revealed  the  existence  of  neuro-retinitis.  Treatment  with  deriva- 
tives improved  the  power  of  sight,  but  produced  no  noteworthy  changes 
in  the  condition  of  the  fundus  of  the  eye. 

Medication  was  also  unsuccessful  in  five  cases  of  saturnine  neuro-retini- 
tis reported  by  Hutchinson  (Ophthalm.  Hosp.  Rep.,  VII.).  A  case  of  sat- 
urnine bilateral  neuro-retinitis  (numerous  white  spots  around  the  optic 
papilla),  with  complete  recovery  from  the  ocular  affection,  has  been  re- 
cently published  by  Strieker  (Ber.  Charite-AnnaL,  I.,  1874). 

The  motor  and  sensory  disturbances,  occurring  in  the  course  of  satur- 
nine affections,  often  assume  the  characteristics  of  medullary  symptoms. 
The  exaggeration  of  sensibility  may  manifest  itself  by  hyperaesthesia  of 
the  superficial  parts,  or  by  neuralgias  of  the  deeper  parts.  The  cutane- 
ous hyperassthesia,  as  I  have  observed  in  several  cases,  often  accompanies 
the  paroxysms  of  pain,  and  after  the  disappearance  of  the  latter  is  only 
present  to  a  slight  degree.  This  hyperaesthesia,  which  is  barely  alluded 
to  by  authors,  alternates  very  frequently  with  ana?sthesia,  and  is  there- 
fore somewhat  similar  to  hysterical  sensory  disorders,  with  their  variable 
manifestations. 

The  symptoms  which  are  described  by  authors  under  the  term  ar- 
thralgia, are,  in  my  opinion,  of  a  neuralgic  character,  and  should  be  re- 
garded as  vague  neuralgias.  This  is  proven  by  their  periodicity,  their 
frequent  relapses,  the  presence  of  points  in  the  neighborhood  of  the  ver- 
tebral column,  which  are  painful  upon  pressure,  the  partial  muscular 
spasms,  and  the  sensations  of  pricking  or  numbness  which  are  experi- 
enced at  the  close  of  an  attack.  These  neuralgias  may  occur  in  the 
upper  or  lower  limbs,  in  the  lumbar  region,  the  intercostal  spaces,  and 
even  in  the  branches  of  the  trigeminus.  The  boring  or  tearing  pains 
chiefly  involve  the  flexor  muscles,  the  extensors  being  more  subject  to 
paralysis.  According  to  Tanquerel's  observations,  there  were  thirty-two 
cases  of  arthralgia  among  fifty-two  of  lead  colic.  Sieveking  (Lancet,  I., 
18G1)  found  seven  cases  of  lead  neuralgia  in  men,  and  only  one  (of  doubt- 
ful character)  in  a  woman. 

Lead  antesthesia  is  a  more  frequent  symptom,  and  considerable  atten- 
tion has  been  devoted  to  it.  Beau  (Arch.  Gen.,  184:8)  observed  ansesthe- 
sia  upon  the  upper  or  inner  surfaces  of  the  limbs,  and  more  rarely  upon 
the  trunk  and  head,  among  thirty  workers  in  lead.  Touching  or  tickling 
the  mucous  membranes  did  not  produce  any  painful  sensations  in  these 
patients.  In  other  parts,  tactile  sensibility  was  preserved,  but  analgesia 
was  present. 

Falk  distinguishes,  in  chronic  saturnine  affections  (Virch.  Handb.  der  Path.  u. 
Ther.,  p.  210  a  superficial  and  deep  anaesthesia.  When  improvement  begins,  the  lat- 
ter disappears  sooner  than  the  former.  Smoler  found  more  or  less  marked  cutaneoua 
analgesia  in  fifteen  cases  of  lead- poisoning ;  anaesthesia  was  not  present,  but  cutaneous 
impressions  were  poorly  localized. 

Archambault  has  recently  published  some  analogous  observations.  In  lead  paraly- 
sis, attended  by  abolition  of  the  excitability  of  the  nerve- trunks,  I  have  found  a 
large  portion  of  the  paralyzed  parts  analgesic,  but  the  sensibility  to  contact  was 
usually  preserved.     In  much  rarer  instances,  and  irrespective  of  the  paralysis,  the  sen- 


140  CLINICAL   TREATISE    ON 

sation  of  burning,  which  is  produced  by  stroking  the  skin  with  the  cathode  of  a  gal- 
vanic battery,  is  lost,  although  the  mere  contact  of  the  electrode  with  the  skin  is  ielt 
with  perfect  distinctness.  There  is  no  doubt  that  the  analgesia  occurring  in  lead 
poisoning  is  of  spinal  origin.  In  two  cases  of  lead  poisoning,  with  abolition  of  sensa- 
tion and  loss  of  consciousness,  Tanquerel  observed  catalepsy  with  "  waxen  flexibility." 

Saturnine  motor  disturbances  are  much  more  severe  than  the  disorders 
of  sensation.  They  may  involve  almost  all  the  muscles  of  the  body, . 
Trousseau  has  observed  paralysis  of  the  muscles  of  the  glottis  in 
horses  employed  in  red-lead  factories.  The  respiration  of  these  ani- 
mals is  normal  during  repose,  but  when  in  motion  it  becomes  hurried 
and  noisy,  the  entire  body  is  tremulous  and  bathed  in  perspiration,  and, 
finally,  they  fall  down  exhausted.  If  the  disease  continues,  the  life  of 
the  animals  can  only  be  saved  by  performing  tracheotomy  and  keeping- 
the  fistula  open  for  several  years.  Guenther,  Gurlt,  and  Hedwig  have 
observed,  upon  autopsy,  in  cases  of  this  character,  atrophy  and  discolora- 
tion of  the  recurrent  nerves,  with  atrophy  and  fatty  degeneration  of  the 
dilators  of  the  glottis. 

According  to  Romberg,  the  left  half  of  the  larynx  would  be  usually  more  affected 
in  the  analogous  condition  in  man,  and  would  be  pressed  inwards  more  rapidly  than 
on  the  healthy  side.  Upon  exercising  energetic  and  prolonged  pressure  upon  the  ary- 
tenoid cartilage  of  the  affected  side,  the  healthy  half  of  the  larynx  being  fixed,  we 
would  observe  acceleration  of  the  respiration  and  increased  violence  of  the  respiratory 
movements.  Independently  of  these  signs,  laryngoscopic  examination  in  man  would 
furnish  important  data  concerning  the  shape  of  the  glottis,  and  would  reveal  diüioulty 
in  or  abolition  of,  the  movements  of  the  vocal  cord  upon  the  affected  side.  Tanquerel 
has  observed  sixteen  cases  of  aphonia,  and  fifteen  cases  of  stammering  and  stuttering 
(psellismus  saturninus)  from  partial  paralyses  in  the  laryngeal  region.  Baglivi  and 
De  Haen  refer  to  analogous  cases.  These  paralyses  of  the  muscles  of  the  larynx  and 
of  speech  are  often  combined  with  partial  paralyses  of  the  muscles  of  the  trunk,  and 
almost  always  pursue  a  chronic  course. 

Lead  paralysis  develops  after  a  condition  of  exhaustion  of  the  vital 
energies  has  become  manifest.  It  may  involve  isolated  groups  of  muscles 
or  the  entire  muscular  tissue  of  the  upper  or  lower  limbs;  it  more  rarely 
involves  the  muscles  of  the  thorax  and  back,  those  of  phonation  and 
speech,  the  intercostal  muscles  and  the  diaphragm  (Duchenne).  Among 
ninety-eight  cases  of  paralysis  of  the  upper  limbs,  Tanquerel  has  only 
seen  this  condition  general  in  five,  and  only  once  among  fifteen  cases  of 
paralysis  in  the  lower  limbs;  in  all  the  others,  the  paralysis  was  partial. 
Lead  paralysis  usually  affects  the  muscles  in  a  regular  order.  Paralysis 
of  the  common  extensor  of  the  fingers  is  followed  by  paralysis  of  the  ex- 
tensors of  the  index  and  little  finger.  Then  the  long  extensor  of  the 
thumb,  the  extensors  of  the  wrist,  the  short  extensor  and  the  long  ab- 
ductor of  the  thumb,  become  affected. 

The  long  supinator  usually  preserves  its  electrical  excitability;  in  ex- 
tensive paralysis,  the  deltoid  and  triceps  are  affected  earlier  than  the 
biceps.  I  have,  however,  observed  and  published  a  case  in  which  the 
paralysis  was  propagated  from  above  downwards.  Paralysis  of  the  lower 
limbs  is  much  more  infrequent  and  chiefly  involves  the  extensors  of  the 
thigh  and  leg.  Lead  hemiplegia,  described  by  Stoll,  Tanquerel,  and  Andral, 
is  exceedingly  rare.  In  the  paraplegic  form,  the  sphincters  are  always  un- 
affected. 

Among  the  anatomical  lesions,  the  older  observers  found  atrophy, 
fatty  degeneration  and  discoloration  of  the  paralyzed  muscles,  contrac- 
tion of  the  blood-vessels,  and  diminution  of  the  hemato-globuline  in  the 


DISEASES    OF   THE    NERVOUS    SYSTEM.  141 

blood.  Lanceraux  (Gaz.  Med.,  Nov.,  1862)  found  granular  or  fatty  degen- 
eration of  the  myeline.  Gombault  (Arch,  de  physiol.,  IV.,  1875)  has  re- 
cently published  a  case  of  lead  paralysis  of  the  upper  and  lower  limbs  in 
a  florist;  the  spinal  cord  and  nerve-roots  were  intact;  in  the  muscles,  the 
transverse  strife  were  only  preserved  in  places,  and  here  and  there  the 
volume  of  the  muscular  fibrillse  was  increased,  with  formation  of  fissures 
and  proliferation  of  nuclei.  In  the  peripheral  nerves,  side  by  side  with 
intact  fibres  of  the  radial  nerve,  were  others  whose  myeline  presented  a 
granular  appearance,  and  certain  sheaths  were  almost  entirely  empty, 
although  the  axis  cylinders  were  well  preserved.  Upon  transverse  sec- 
tion, nuclear  proliferation  was  found  in  the  intra-fascicular  connective  tis- 
sue. In  a  case  of  lead  paralysis  reported  by  Westphal  (Arch.  f.  Psychiat., 
IV.  Bd.,  1874),  the  affected  muscles  were  emaciated,  with  partial  disap- 
pearance of  the  transverse  striae  and  multiplication  of  the  muscular  nuclei. 
Upon  transverse  section  of  the  radial  nerve  after  hardening,  the  myeline 
of  the  fibres  was  found  to  have  been  markedly  diminished  in  quantity; 
the  intermediate  spaces,  which  were  streaked  with  red  and  feebly  colored, 
were  grouped  under  the  form  of  small  circles  and  represented  transverse  sec- 
tions of  the  nerve-fibres,  such  as  are  observed  in  regenerated  nerves.  These 
fibres  were  more  numerous  in  the  nerve-trunk  than  in  its  branches  (primary 
affection  of  the  radial  nerve);  the  cord,  the  anterior  horns,  and  the  nerve- 
roots  were  intact. 

In  one  case  of  chronic  lead  poisoning  (with  dyspepsia,  colic,  vomiting, 
diarrhoea,  and  fatal  collapse),  Kussmaul  and  Mayer  observed  (Deutsch. 
Arch.  f.  klin.  Med.,  IX.  Bd.,  H.  II.)  sclerosis  of  the  coeliac  and  upper 
cervical  ganglia,  with  proliferation  of  the  connective  tissue  and  deformity 
of  the  cells;  the  brain  and  cord  presented  a  slight  grade  of  periarteritis 
(an  inflammatory  change  in  the  cerebral  capillaries  may  give  rise,  in  lead 
poisoning,  to  rupture  of  the  vessels  and  extravasations  of  blood).  In  ad- 
dition, the  mucous  and  muscular  coats  of  the  stomach  were  found  atro- 
phied. Peyer's  patches  and  the  solitary  follicles  were  diminished  in  num- 
ber and  extremely  atrophied,  and  the  submucous  coat  of  the  intestines 
was  thickened  from  an  abundant  proliferation  of  the  connective  tissue. 
The  dyspepsia  must  therefore  be  attributed  to  chronic  gastro-intestinal 
catarrh,  with  atrophy  of  the  lymphatic  glands.  During  the  attacks  of 
colic,  there  is  irritation  of  the  sensory  fibres  of  the  abdominal  ganglia 
and  of  the  connective  tissue  which  surrounds  and  traverses  these  organs. 
Segond  has  also  found  the  coeliac  ganglion  indurated  in  patients  who  had 
died  from  the  endemic  colic  of  Cayenne.  According  to  Tanquerel,  this 
disease,  as  well  as  the  colic  of  Poitou,  of  Devonshire,  and  of  Madrid,  is  the 
result  of  lead  poisoning. 

Electrical  exploration  in  lead  paralysis  furnishes  many  points  of  inter- 
est, both  from  a  scientific  and  a  practical  point  of  view.  Electricity  was 
first  successfully  employed  by  Gardane  (Conject.  sur  I'electricite  med., 
etc.,  Paris,  1768),  and  soon  after  by  De  Haen  (Ratio  medendi,  t.  III.,  1771). 
In  the  beginning  of  this  century,  electro-puncture  was  in  vogue.  The 
English  physicians  employed  statical  electricity,  by  allowing  the  sparks' 
of  an  electrical  machine  to  pass  to  the  dorsal  spine. 

At  a  later  period,  the  researches  of  Duchenne  showed  that  electrical 
contractility  and  sensibility  are  diminished  in  the  paralyzed  muscles,  and 
that  the  contractility  becomes  affected  in  them  in  the  order  which  we 
have  previously  pointed  out.  Atrophied  muscles,  which  do  not  contract 
under  the  stimulus  of  electricity,  are  not  susceptible  of  spontaneous  re- 
covery; if  a  strong  current  is  applied,  it  will  pass  through  the  atrophied 


142  CLINICAL   TREATISE    OH" 

extensors  to  the  flexors.  In  many  cases  which  have  come  under  my  ob- 
servation, the  electro-muscular  contractility  was  affected  before  voluntary 
motion;  during  the  progress  of  recovery,  the  latter  may  be  re-established, 
while  the  electro-muscular  contractility  is  still  decidedly  below  the  nor- 
mal. In  some  cases  of  lead  paralysis,  Eulenburg  and  Erb  have  observed 
abolition  of  farado-muscular  with  preservation  of  galvano-muscular  con- 
tractility. 

In  severe  and  extensive  forms  of  paralysis  we  are  able  to  follow  (as  I 
have  shown  in  my  treatise  on  electrotherapeutics)  the  diminution  or  abo- 
lition of  galvanic  excitability  from  the  nerve-roots  to  the  plexuses  and 
nerve-trunks  ;  in  less  extensive  paralysis,  the  nerve-roots  preserve  their 
excitability  to  galvanism.  The  excitability  may  therefore  persist  in  the 
parts  adjacent  to  the  spinal  centres,  although  it  has  disappeared  in  the 
peripheral  regions;  it  may  also  be  preserved  in  the  plexuses,  after  it 
has  been  abolished  in  the  nerve-trunks.  If  recovery  takes  place,  the 
return  of  excitability  occurs  from  the  centre  to  the  periphery,  and  gradu- 
ally advances  from  the  nerve-roots  and  plexuses  to  the  trunks  of  the 
nerves. 

The  treatment  of  saturnine  affections  has  for  its  object  the  elimina- 
tion of  the  poison  from  the  system  and  the  palliation  of  the  distressing 
symptoms  of  the  disease.  Great  advantage  is  obtained  in  lead  colic  from 
the  employment  of  large  doses  of  opium.  In  very  painful  attacks,  the 
drug  should  be  administered  in  such  a  manner  that  it  may  be  readily  ab- 
sorbed. In  the  course  of  my  experiments  upon  resorption  and  absorption 
of  preparations  of  iodine  (Sitz.  d.  Kais.  Akad.  d.  Wiss.,  XLVI.  Bd.,  1872, 
and  Med.  Wschr.,  1863),  I  incidentally  demonstrated  the  practical  advan- 
tages of  enemata  containing  opium,  and  of  intestinal  absorption  in  lead 
colic.  Hypodermic  injections  of  preparations  of  opium  or  belladonna 
act  even  more  rapidly.  The  injection  should  be  repeated  as  soon  as  the 
first  signs  of  another  attack  become  manifest;  in  rebellious  cases,  we  may 
also  administer  the  opium  during  the  remissions.  According  to  Didier- 
jean  (Gaz.  hebdom.,  VII.,  1870),  workers  in  lead  factories  who  are  in  the 
habit  of  drinking  milk  several  times  a  day,  are  not  subject  to  colic  or  to 
other  saturnine  affections. 


The  treatment  with  iodide  of  potassium,  first  recommended  by  Melseus,  is  usually 
employed  in  the  various  forms  of  lead  poisoning.  It  is  held  that  the  iodide  of  potas- 
sium forms  a  soluble  combination  with  the  lead  which  has  accumulated  in  the  organ- 
ism, and  thus  favors  its  elimination  from  the  body.  According  to  the  careful  fexperi- 
ments  of  Overbeck,  Waller,  and  Schneider  in  Vienna,  the  administration  of  iodide  of 
potassium  does  not  favor  the  elimination  of  mercury  to  any  marked  extent.  This 
fact  being  demonstrated  with  regard  to  mercury,  there  is  no  good  reason  for  admitting 
a  more  active  elimination  of  lead  under  the  influence  of  this  drug.  The  deficiency  in 
experimental  investigations  upon  this  question,  is  not  supplied  by  the  results  of  clini- 
cal observations.  In  chronic  lead  poisoning,  the  combinations  of  lead  are  only  elimi- 
nated through  the  natural  emunctories  (liver,  digestive  canal,  kidneys)  after  a  long 
time.  So  long  as  the  organism  has  not  recovered  its  normal  functions  under  the  in- 
fluence of  a  vital  reinvigoration,  iodide  of  potassium  will  not  aid  in  the  restoration  of 
the  diseased  economy,  and  in  the  regulation  of  its  disordered  functions. 

I  have  obtained  no  better  results,  in  lead  cachexia^  from  the  immedi- 
ate employment  of  electrical  treatment,  than  from  the  use  of  iodide  of 
potassium.  Electricity  has  proved  useful  in  my  hands,  only  after  the 
general  condition  has  improved  under  the  influence  of  warm  baths,  pure 
air,  nutritious  diet,  and  wines.     In  view  of  the  facts   to  which  we  have 


DISEASES    OF    THE    NERVOUS    SYSTEM.  143 

called  attention  above,  it  is  necessary,  in  severe  cases  of  lead  paralysis, 
to  expose,  as  far  as  possible,  the  central  portions  of  the  nerve-paths  to 
the  action  of  the  current,  and  to  pass  the  labile  descending  galvanic  cur- 
rent (eight  to  ten  minutes  daily)  from  the  nerve-roots  to  the  plexuses  and 
nerve-trunks.  The  galvanic  current  can  act  in  this  manner  upon  the 
nerves  at  a  period  in  which  the  intra-muscular  nerve-fibres  will  not  per- 
mit the  current  to  pass  through  them,  and  in  which  the  local  application 
of  faradism  possesses,  therefore,  very  little  utility.  It  is  preferable,  in 
the  majority  of  cases,  to  resort  to  a  mixed  treatment,  by  alternating, 
every  other  day,  galvanization  of  the  nerve-trunks  with  faradization  of 
the  paralyzed  muscles.  In  severe  cases,  recovery  does  not  occur  until 
the  expiration  of  several  months. 

Experience  has  shown  that  repeated  warm  baths,  and  after  a  time, 
vapor  baths  of  short  duration,  followed  by  douches  to  the  paralyzed 
limbs,  produce  good  results  in  lead  cachexia,  while,  as  a  rule,  the  patients 
tolerate  cold  baths  very  poorly.  The  good  effects  of  sulphur  baths, 
which  are  praised  so  highly  by  Tanquerel,  are  due  less  to  the  sulphur 
than  to  the  temperature  of  the  bath.  Preparations  of  strychnine  and 
brucine  which  were  recommended  by  Fouquier,  have  been  also  highly 
praised  by  Tanquerel.  Among  forty  cases  treated  in  this  manner,  the 
larger  number  recovered  completely  and  the  remainder  were  considerably 
improved.  In  one  case  of  lead  paralysis,  I  obtained  good  effects  from 
the  employment  of  hypodermic  injections  of  strychnine  (one  to  five 
milligrammes  on  alternate  days).  Finally,  hydrotherapeutic  measures 
are  very  efficient  in  lead  dyscrasia  and  its  sequences.  At  first,  moist 
frictions  should  be  employed  daily,  followed  by  half-baths  at  18  °-16  °  C. ; 
we  may  then  resort  to  moist  packs  (until  the  body  becomes  warm),  to 
affusions  in  a  half-bath,  and  finally  to  local  douches  or  to  whole  baths  of 
short  duration.  I  have  been  able  to  convince  myself  that  this  method 
furnishes  excellent  results. 

The  consideration  of  mercurial  nervous  affections  will  next  engage 
our  attention. 

They  are  due  to  the  absorption  of  mercury  through  the  skin  or  mucous 
membranes,  or  to  the  inhalation  of  vapor  of  mercury  floating  in  the  at- 
mosphere, and  may  cause  more  or  less  profound  disturbances  in  the  peri- 
pheral and  central  organs.  In  the  latter  event,  mercurial  arthralgia  oc- 
curs, combined  with  tremor  of  the  upper  and  lower  limbs,  general  paraly- 
sis of  the  arms  and  legs  and  affections  of  the  organs  of  special  sense. 
When  the  brain  becomes  affected  by  the  toxic  agent,  vertigo,  insomnia, 
hypochondria,  epileptiform  attacks,  and  sometimes,  though  rarely,  mania 
and  idiocy,  make  their  appearance. 

From  a  therapeutic  point  of  view,  after  having  removed  the  patient 
from  the  influence  of  the  poison,  we  may  hasten  elimination  by  stimulat- 
ing the  intestinal  and  renal  functions  by  means  of  baths  and  a  trip  to  the 
countrv.  I  have  obtained  good  results  in  several  cases  of  mercurial  tremor 
and  paresis  from  galvanization  of  the  nerves  or  faradic  treatment  of  the 
paretic  muscles. 

In  chronic  arsenical  poisoning,  tremor  of  the  limbs,  atrophy,  and  pa- 
ralysis of  the  extensors  of  the  upper  limbs,  and  paraplegia  may  develop 
in  the  midst  of  cephalic  symptoms,  vague  neuralgias,  and  sensations  of 
numbness  and  anfesthesia.  In  one  case  which  I  have  published,  and  in  a 
second  observation  by  Smoler  (Zeitschr.  f.  prak.  Heilk.,  19,  20,  1863),  the 
electro-muscular  contractility  and  sensibility  were  considerably  diminished. 
In  the  latter  patient,  whose  limbs  remained  paretic  for  a  long  time,  im- 


144  CLINICAL   TKEATISE    ON 

provement  of  electrical  contractility  and  a  return  of  motor  power  rapidly 
occurred  after  daily  faradization  of  the  muscles. 

The  paralyses  and  disorders  of  speech  produced  by  carbonic  oxide  are 
attributed  (but  only  in  severe  cases)  to  the  development  of  foci  of  cere- 
bral softening  (Th.  Simon).  Atrophy  and  paralysis  of  the  limbs  from  in- 
halations of  sulphide  of  carbon  (workers  in  caoutchouc  factories,  Del- 
pech)  occur  very  rarely.  This  is  also  true  of  the  paralysis  of  the  fingers 
from  a?iiline  poisoning  (as  in  Clemens'  case  of  wound  of  the  skin),  of  the 
phosphorus  2)aralyses  of  the  forearm  (Gallavardin),  and  of  the  paralyses 
due  to  acute  poisoning  (from  hydrocyanic  acid,  nicotine,  etc.). 


DISEASES    OF    THE    NERVOUS    SYSTEM.  145 


CHAPTER  XXXVIII. 

NERVOUS    AFFECTIONS   DUE   TO    FEBRILE   DISEASES. 

Nervous  disturbances  and  multiple  paralyses  may  be  observed,  both 
during  the  course  and  after  the  termination  of  febrile  affections.  These 
disorders  are  the  expression  of  phenomena  of  irritation  or  of  depression 
in  the  cerebro-spinal  system,  or  of  peripheral  changes  occurring  in  the 
nerves  and  muscles.  The  anatomical  character  of  these  lesions  is  not 
sufficiently  understood  from  all  points  of  view.  In  the  present  chapter 
we  shall  discuss  those  nervous  disorders  which  occur  during  febrile  affec- 
tions (febrile)  and  those  which  follow  them  (post-febrile). 

N^ervous  disorders  occurring  in  infectious  diseases. — An  entire  series 
of  nervous  disorders,  from  slighter  to  more  severe  manifestations,  may 
occur  during  the  course  of  typhoid  fever.  Hyperaesthesia  is  the  earliest 
disturbance  of  sensation,  and  has  been  especially  investigated  by  Fritz 
(Gaz.  Med.,  5-7,  1864).  It  is  one  of  the  first  symptoms  of  the  disease, 
and  may  last  a  few  days  or  continue  into  the  second  week.  This  hyper- 
aesthesia is  chiefly  observed  in  women  and  children,  and  may  be  so  marked 
that  pinching  up  a  fold  of  skin,  slight  pressure  of  the  nails,  and  even,  in 
the  most  severe  cases,  the  weight  of  the  clothes,  give  rise  to  intense 
pains. 

The  cutaneous  hyperaesthesia  usually  involves  a  considerable  portion 
of  the  limbs  or  trunk,  and  it  generally  pursues  an  ascending  direction. 
Muscular  hyperaesthesia,  often  combined  with  spontaneous  muscular  pains 
and  cutaneous  hyperaesthesia,  is  the  cause  of  intolerable  suffering  to  the 
patients.  It  renders  all  movement  impossible,  condemns  them  to  absolute 
rest,  and  may  terminate  in  distressing  contractures.  Muscular  hyperaes- 
thesia may  involve  almost  all  the  muscles  of  the  limbs,  neck,  thorax,  and 
abdomen,  and  usually  occurs  simultaneously  with  the  cutaneous  hyperaes- 
thesia. More  or  less  extensive  anaesthesia  is  often  a  very  rebellious  symp- 
tom, and  almost  always  occurs  during  convalescence.  I  have  observed 
anf^sthesia  of  the  superficial  layers  and  hyperaesthesia  of  the  deeper  parts 
(as  Tuerck  has  noticed  in  neuralgia)  in  the  calves  of  the  legs  after  typhoid 
fever. 

In  a  convalescent  from  typhoid  fever,  set.  twenty  years,  anaesthesia  of  the  left  me- 
dian nerve  was  observed,  and  also  of  the  anterior  and  external  surfaces  of  the  lower 
limb  upon  the  same  side,  with  right  mydriasis  and  feebleness  of  accommodation,  and 
loss  of  hearing  on  the  right  side  (the  ticking  of  a  watch  was  only  audible  when  applied 
directly  to  the  concha  ;  the  membrana  tympana  was  found  normal  by  Politzer).  Upon 
passing  strong  galvanic  currents  from  the  dorsal  spine  to  the  brachial  plexus,  or  from 
the  plexus  to  the  median  nerve,  peripheral  sensibility  was  found  to  be  absent  in  the 
first  three  fingers ;  motor  power  was  preserved.  Galvanization  produced  rapid  im- 
provement. 

Among  the  nervous  disorders  of  typhoid  fever  we  may  also  mention 
the  neuralgic  pains  which  occur  during  the  first  week  in  certain  nerves 
Vol.  II.— 10 


146  CLimCAL   TEEATISE    ON 

(frequently  the  occipital  or  supraorbital),  or  may  develop  after  the  ter- 
mination of  the  disease  in  the  vertebral  column,  the  loins,  in  the  nerves  of 
the  arms  or  feet,  and  may  even  be  accompanied  by  temporary  hyperaes- 
thesia. 

We  have  previously  spoken  of  contractures  as  among  the  motor  dis- 
turbances occurring  in  the  train  of  typhoid  fever.  It  may  also  be  fol- 
lowed by  various  paralyses.  Thus  paralysis  of  the  vocal  cords  has  been 
observed  by  Tuerck  in  adults,  and  by  Bierbaum  and  Friedreich  in  children. 
Hervieux  and  Griesinger  have  published  cases  of  ptosis  and  external  stra- 
bismus. 

In  one  case  of  this  kind,  which  terminated  in  death,  no  changes  were 
found  in  the  brain  or  nerves.  Wunderlich,  Griesinger,  and  Seitz  men- 
tion examples  of  complete  or  incomplete  paralysis  of  the  lower  limbs.  In 
an  observation  made  by  Leudet  (Gaz.  des  Hop.,  58,  1861),  ascending  pa- 
ralysis developed  during  convalescence  from  a  mild  attack  of  typhoid  fever, 
and  extended  from  the  lower  to  the  upper  limbs,  then  to  the  muscles  of 
respiration,  and  terminated  in  death  after  a  duration  of  six  days.  No 
changes  were  found  in  the  nerve-centres  or  in  the  larynx.  M.  Meyer  re- 
ported the  case  of  a  boy,  set.  sixteen  years,  who  suffered  from  anaesthesia 
of  the  right  half  of  the  body,  atrophy  of  the  right  arm,  and  complete  pa- 
ralysis of  the  muscles  supplied  by  the  right  ulnar  nerve,  during  convales- 
cence from  typhoid  fever.  From  the  observations  which  I  made  in  the 
Vienna  General  Hospital  during  two  epidemics  of  typhoid  fever,  it  appears 
that  the  paralyses  vary  in  extent  and  intensity.  In  slight  cases  there  is 
merely  paresis  of  certain  groups  of  muscles,  the  patients  cannot  "  make  a 
fist,"  the  grip  is  very  feeble,  writing  is  accomplished  with  difficulty,  and 
the  electro-muscular  and  electro-cutaneous  sensibility  are  markedly  di- 
minished. In  severe  and,  fortunately,  rarer  cases  the  paralysis  may  in- 
volve one  side  of  the  body  or  both  lower  limbs. 

I  observed  left  hemiplegia  in  a  young  man,  aet.  twenty-six  years,  five  months 
after  a  severe  attack  of  typhoid  fever.  The  movements  at  the  shoulder  and  elbow 
were  seriously  interfered  with,  and  those  at  the  ankle-joint  were  only  accomplished 
with  great  effort.  The  electro-muscular  contractility  was  diminished  in  the  leg  (com- 
pared to  the  healthy  side). 

In  two  cases  (boys  of  fourteen  and  sixteen  years  of  age)  marked  paralysis  of  the 
lower  limbs,  which  had  been  mistaken  by  several  physicians  for  spinal  paralysis,  de- 
veloped six  and  nine  months  respectively  after  typhoid  fever.  The  electro-muscular 
contractility  and  the  galvanic  excitability  of  the  nerves  were  extremely  feeble  or  abol- 
ished in  the  lower  limbs.  Sensibility  and,  finally,  motion  were  gradually  restored 
under  the  influence  of  warm  baths  and  nutritious  diet.  The  galvanic  excitability  of 
the  nerves  then  reappeared,  while  the  electro-muscular  contractility  returned  more 
slowly,  especially  in  the  legs,  and  was  not  entirely  restored  even  after  the  patient  was 
able  to  walk. 

The  nervous  disorders  which  develop  during  or  after  typhoid  fever 
may  be  of  central  or  peripheral  origin.  As  proof  of  their  cerebral  nature, 
■we  often  observe  symptoms  of  irritation  or  depression  (unilateral  con- 
tractures, tremors,  aphasia,  partial  or  maniacal  delirium,  acute  insanity, 
hemiplegia  with  preservation  of  electro-muscular  contractility).  The 
spinal  origin  of  many  of  the  nervous  disorders  in  question  is  demonstrat- 
ed by  certain  coexisting  symptoms  (extensive  hyperaesthesia  or  ana3sthe- 
sia  on  both  sides  of  the  body,  paralysis  of  the  bladder  and  rectum) ;  by 
the  acute  ascending  paralysis,  observed  by  Leudet,  affecting  the  lower 
limbs  and  then  the  arrms,  and  rapidly  terminating  in  death  j  by  the  oc- 


DISEASES    OF   THE    NERVOUS    SYSTEM.  147 

currence  of  progressive  muscular  atrophy,  ataxia,  and  sclerosis  of  the 
cord,  after  typhoid  fever;  finally,  by  the  atrophy  of  the  sympathetic 
observed  by  Astegiano  in  a  patient  suffering  from  ulcerations  extending 
over  one-half  of  the  body.  Beau  reports  four  cases  in  which,  in  addition 
to  spinal  hyperjemia,  foyers  of  softening  occurred  in  the  gray  matter. 
Certain  monoplegias  occurring  after  typhoid  fever  are  of  peripheral  ori- 
gin. These  include  the  paralysis  of  distinct  groups  of  muscles,  w^ith  par- 
tial anaesthesia  and  abolition  of  electrical  excitability,  due  to  nutritive 
disorders  in  the  corresponding  nerves.  In  some  cases  these  symptoms 
may  be  attributed  to  neuritis.  Zenker  has  demonstrated  the  peripheral 
character  of  a  large  number  of  paralyses  following  typhoid  fever,  by 
pointing  out  the  anatomical  lesions  of  the  muscular  tissue  (Veränder- 
ungen der  willkürl.  Muskeln  im  Typhus  abdom.,  1864).  This  writer  dis- 
tinguishes a  granular  degeneration  (deposit  of  fine  molecular  granules  in 
the  contractile  substance  of  the  muscular  fibres)  and  a  waxy  degeneration 
(transformation  of  the  contractile  substance  into  a  homogeneous,  color- 
less, glistening  mass,  with  disappearance  of  the  transverse  strife).  These 
degenerations  occur  most  frequently  in  the  adductors  of  the  thigh,  the 
transversalis  abdominis,  the  psoas,  obturators,  triceps,  and  pectoralis 
minor.  They  sometimes  develop  symmetrically  upon  both  sides  of  the 
body.  They  appear  to  attain  their  greatest  development  during  the  sec- 
ond or  in  the  beginning  of  the  third  week,  remain  stationary  during 
the  third  and  fourth  weeks,  and  disappear  during  the  fifth  or  six 
weeks. 

At  this  period,  the  perimysium  is  found  to  contain  cells  which  are 
either  small,  round,  or  angular,  or  are  large,  fusiform,  or  stellate;  elon- 
gated fibres  are  also  scattered  throughout  groups  of  nuclei,  and  the  trans- 
formation of  these  into  muscular  fibres  is  demonstrated  by  the  appear- 
ance of  transverse  strife  in  them.  They  present  a  great  analogy  with  the 
appearances  presented  during  the  embryonic  development  of  striated 
muscles.  According  to  Waldeyer,  the  regeneration  of  the  fibres  occurs 
from  rows  of  "muscle-cells,"  and,  according  to  E.  Neumann,  from  longi- 
tudinal fission  of  the  old  fibres. 

The  alterations  in  the  muscular  tissue,  which  were  afterwards  de- 
scribed by  Hayem  (Arch,  de  Physiol.,  T.  III.,  1870)  in  typhoid  fever  and 
other  febrile  affections,  are  of  an  inflammatory  nature.  Popoff  (Virch. 
Arch.,  61.  Bd.,  1874)  has  observed  granular  transformation  of  the  muscu- 
lar tissue  (parenchymatous  muscular  inflammation,  Virchow)  in  a  large 
number  of  infectious  diseases  (typhoid  and  typhus  fevers,  cholera,  re- 
current fever,  puerperal  affections,  pyaemia).  Side  by  side  with  the 
waxy  degeneration  and  increase  in  the  nuclei  of  the  muscular  fibres,  in- 
flammatory changes  occur  in  the  internal  and  middle  coats  of  the  vessels 
in  the  affected  muscles.  This  produces  a  diminished  power  of  resistance 
in  the  walls  of  the  vessels,  and  thus  explains  the  vascular  ruptures  and 
haemorrhages  observed  in  the  muscular  tissues.  The  arteries  of  other 
organs  present  no  abnormal  cl  anges. 

The  prognosis  of  the  nervous  disorders  under  consideration  is  favor- 
able. In  the  majority  of  cases  they  terminate  in  recovery,  though  this 
may  occupy  from  three  to  seven  months  in  the  paraplegic  forms  (Ken- 
nedy, Rilliet).  If  convalescence  is  very  prolonged,  we  may  prescribe 
with  advantage  a  trip  to  the  country  and  light  ferruginous  waters.  In 
persistent  anaesthesia  and  paresis  of  the  limbs  good  effects  are  obtained 
from  electro-therapeutics  (galvanization  of  the  nerve-trunks,  faradization 
of  the  skin  and  muscles)  and  from  hydrotherapeutics  (frictions,  packs  of 


148  CLINICAL    TREATISE    ON 

short  duration,  cool  half-baths;  local  douches  in  anaesthesia).  If  the 
psychical  disturbances  are  prolonged,  we  may  resort  to  mild  hydrothera- 
peutic  measures.  In  conditions  of  excitement,  Delasiauve  recommends 
enemata  containing  quinine  and  camphor.  In  severe  forms,  associated 
:  with  torpor,  acetate  of  ammonia  (thirty  to  forty  drops  daily)  may  be  em- 
ployed, with  exercise  in  the  open  air,  travel,  and  moral  treatment. 

Nervous  disorders  following  acute  febrile  diseases  and  the  exanthe- 
mata.— Motor  and  sensory  disturbances  are  also  observed  as  sequences  of 
acute  articular  rheumatism,  pneumonia,  pleurisy  (Durozier),  bronchitis 
and  tuberculosis.  The  motor  disorders  have  been  described  by  Gubler 
(Arch,  gen.,  1860)  under  the  term  "  amyotrophic  paralysis,"  but  they  do 
not  always  result,  as  he  believes,  from  neuritis  with  nutritive  disturb- 
ances in  the  muscular  tissues.  I  have  published  a  case  of  paraplegia  fol- 
lowing pneumonia,  in  which  the  paralysis  of  the  right  leg  was  accompa- 
nied by  anjesthesia  of  the  anterior  part  of  the  thigh,  with  diminution  of 
the  electro-muscular  contractility  and  sensibility.  Recovery  occurred 
after  four  weeks'  treatment  with  faradization  and  warm  baths.  We  have 
previously  mentioned,  upon  page  18,  Vol.  I.,  the  abolition  of  electro- 
muscular  contractility  and  sensibility  observed  in  a  case  of  cerebral 
rheumatism  complicated  with  profound  melancholia. 

Numerous  motor  and  sensory  disorders,  either  of  a  central  or  periph- 
eral nature,  may  occur  after  the  acute  exanthemata.  Thus  rubeola  is 
sometimes  followed  by  hemiplegia  (Barthez  and  Rilliet)  and  general 
(Liegeard)  or  circumscribed  paralysis.  Hemiplegia  (Kennedy),  paraple- 
gia (Revillout,  Shepherd),  and  apoplectiform  paralysis  with  persistent 
aphasia  (Eulenburg)  have  been  observed  after  scarlatina.  Variola  is 
sometimes  followed  by  severe  and  rebellious  sequences,  under  the  form  of 
aphasia  (in  a  patient  under  my  care  it  was  accompanied  by  cephalic 
symptoms),  initial  hyperoesthesia  followed  by  anresthesia,  and  coexisting 
paralysis.  The  paralysis  is  sometimes  circumscribed  and  limited  to  the 
upper  limbs,  but  more  frequently  assumes  the  paraplegic  type  and  in- 
volves the  lower  limbs.  In  two  cases  of  this  character,  Westphal  recently 
found  (Arch.  f.  Psych.,  IV.  Bd.)  disseminated  myelitis  (softening  with 
production  of  granular  cells),  involving  the  white  substance,  especially 
the  lateral  columns,  but  also  the  gray  matter.  Similar  lesions  were  found 
in  a  case  of  pulmonary  phthisis,  with  motor  and  sensory  disturbances  in 
the  lower  limbs.  We  may  finally  add  that  paralysis  of  cranial  nerves  and 
paraplegia,  usually  with  a  favorable  termination,  have  been  observed  after 
erysipelas. 

Diphtheritic  nervous  disorders. — Diphtheritic  paralysis  has  been 
carefully  studied  by  Trousseau  (Gaz.  des  Hop.,  1855),  Bretonneau  (xVrch. 
gen.,  1855),  Maingault  (De  la  Paralysie  diphtherique,  18G0),  Jenner 
(Diphtheria,  etc.,  1861),  Weber  (Virch.  Arch.,  1862),  etc.  After  the 
termination  of  the  local  disease,  which  usually  involves  the  pharynx, 
much  less  frequently  the  skin,  nasal  fossa?,  conjunctivas,  vulva,  or  the 
external  auditory  canal,  an  interval  of  several  days  or  weeks  may  elapse 
before  the  first  symptoms  of  the  nervous  affection  become  manifest. 
They  consist,  in  many  cases,  of  violent  vomiting  and  retardation  of  the 
pulse. 

Paralysis  of  the  pharynx  and  velum  palati  (difficulty  of  deglutition, 
nasal  voice,  inability  to  suck,  gargle,  or  blow,  ansesthesia  of  the  uvula  and 
velum  palati,  abolition  of  faradic  excitability)  is  one  of  the  earliest  and 
most  frequent  symptoms.  The  diphtheritic  paralysis  may  then  affect 
various  other  muscles,  the  epiglottis,  vocal  cords,  the  tongue,  the  ocular 


DISEASES    OF    THE    NERVOUS    SYSTEM.  149 

muscles,  the  sphincter  of  the  pupils  and  the  tensor  of  the  choroid  (with 
mydriasis  and  loss  of  accommodation). 

I  have  observed  in  the  St.  Joseph's  Children's  Hospital,  in  Vienna,  an  example  of 
diphtheritic  facial  paralysis,  which  is,  I  believe,  a  unique  case  (Med.  Pres.se,  26,  1868). 
The  middle  paralyzed  muscles  of  the  face  had  lost  their  faradic  contractility,  but 
preserved  their  irritability  to  the  continuous  current.  Even  after  the  disappearance 
of  the  paralysis,  the  same  difference  existed  with  regard  to  the  action  of  the  two  cur- 
rents. The  patient,  aet.  two  and  a  half  years,  died  two  weeks  later  of  chronic  intes- 
tinal catarrh,  and  no  abnormal  appearances  were  discovered  upon  microscopical  ex- 
amination. Negative  results  were  also  obtained  by  Ziemssen  (Die  Elektricität  in 
der  Medizin,  1866)  in  a  case  of  diphtheritic  paralysis  of  the  velum  palati  and  pharynx. 

In  addition  to  the  small  muscles  mentioned  above,  the  paralysis  may 
also  extend  to  the  trunk  and  extremities.  Paralysis  of  all  possible  grades 
may  occur,  from  a  slight  uncertainty  in  the  gait  to  ataxia  (Eisenmann 
and  Brenner),  but  rarely  complete  paralysis.  Electro-muscular  con- 
tractility and  sensibility,  and  the  galvanic  irritability  of  the  nerves,  are 
usually  diminished.  The  latter  is  sometimes  increased,  but  only  in  very 
marked  disorders  of  co-ordination.  The  sensory  disorders  include,  at  the 
onset,  hyperaesthesia,  then  anaesthesia,  and  a  slight  sensation  of  numb- 
ness. The  visual  disturbances  (asthenopia,  dilatation  of  the  pupils, 
hypermetropia,  more  rarely  myopia,  without  any  changes  appreciable 
with  the  ophthalmoscope)  often  appear  simultaneously  with  the  difficulty 
in  deglutition.  The  other  special  senses  are  also  more  or  less  affected. 
During  the  period  of  paralysis  the  bladder  and  rectum  may  become  para- 
lyzed. Trousseau,  Maingault,  etc,  have  observed  impotence  in  young 
men,  lasting  several  weeks  and  sometimes  even  months.  The  character 
of  the  primary  disease  bears  no  relation  to  the  intensity  of  the  secondary 
nervous  affections,  as  some  light  forms  of  diphtheria  are  followed  by 
paralysis,  while  severe  cases  may  terminate  without  any  nervous  compli- 
cations. Among  one  hundred  and  ninety  observations  by  Weber  and 
other  authors,  motor  disturbances  occurred  sixteen  times  (about  8.5  per 
hundred).  In  the  Children's  Hospital  of  Paris,  Roger  found  thirty-six 
cases  of  paralysis  among  two  hundred  and  ten  of  diphtheria,  or  more- 
than  sixteen  per  cent.  The  diphtheritic  poison  may  be  transmitted 
directly  through  solutions  of  continuity  in  the  external  integument. 

lu  Patterson's  case  (Med.  Times,  p.  858,  1868)  a  man  became  affected  with  paral- 
ysis of  all  the  limbs,  in  consequence  of  a  phagedenic  ulceration  of  the  right  index- 
finger.  This  man,  having  a  slight  scratch  upon  the  finger,  had  introduced  it  into  the- 
mouth  of  his  child,  who  was  suffering  from  ordinary  diphtheria.  The  father's  throat 
remained  unaffected.  When  diphtheria  is  epidemic,  surgical  wounds,  even  in  isolated 
patients,  are  predisposed  to  the  development  of  diphtheritic  affections,  as  has  been 
recently  proved  by  the  sad  death  of  the  illustrious  Griesinger.  After  incision  of  a 
large  perityphlitic  abscess  from  which  he  was  suffering,  the  wound  became  diphther- 
itic, but  this  soon  yielded  to  simple  measures.  After  it  had  completely  cicatrized, 
widespread  symptoms  of  paralysis  developed  (muscles  of  speech,  deglutition,  of  the 
limbs,  and  finally  of  respiration),  and  death  ensued  at  the  end  of  the  seventieth  dayv 

In  the  cases  of  sudden  death,  which  Thompson  has  observed  in  con- 
valescents who  presented  retardation  of  the  pulse,  syncope,  vomiting, 
and  often  epileptiform  attacks,  the  right  ventricle  was  found  to  contain 
firm,  laminated  clots,  adherent  to  the  columnae  carneas  and  chordae  ten- 
dinjE.  In  other  cases  the  patients  died  of  fatty  degeneration  of  the 
heart,  of  an  intercurrent  pneumonia,  of  Bright's  disease,  or  of  paralysis 
of  the  diaphragm. 


150  CLINICAL   TREATISE    OTT 

Very  few  observations  have  been  made  with  regard  to  the  anatomical 
changes  in  the  nervous  and  muscular  systems.  According  to  Buhl 
(Zeitschr.  f.  Biol.,  III.  Bd.,  1867),  the  diphtheritic  exudation,  which  con- 
sists of  a  nuclear  infiltration  into  the  connective  and  mucous  tissues,  is 
also  found  in  the  sheaths  of  the  paralyzed  nerves.  Charcot  and  Vulpian 
have  found  a  degeneration  of  the  motor  nerves  of  the  velum  palati  in 
diphtheritic  paralysis  of  the  pharynx.  According  to  Oertel's  experi- 
mental investigations  (Arch.  f.  klin.  Med.,  VIII.  Bd.,  1871),  diphtheria 
in  man  may  be  transmitted  to  animals,  and  is  characterized  by  an  abun- 
dant proliferation  of  micrococcus  spores.  In  a  case  of  diphtheritic 
ataxia,  abundant  nuclear  proliferations  were  found  in  the  mucous  mem- 
branes, in  the  muscular  substance  (with  atrophy  and  fatty  degeneration), 
in  the  meninges  and  vessels  of  the  brain  and  cord,  in  the  anterior  horns 
of  the  cord  and  around  the  central  canal  (a  croupous  exudation  rich  in 
cells),  and  in  the  sheaths  of  the  nerves.  In  addition,  capillary  haemor- 
rhages occurred  in  the  white  and  gray  substance  of  the  nerve-centres 
and  in  the  sheaths  of  the  nerve-roots  and  peripheral  nerves.  Further 
observations  are  necessary  in  order  to  confirm  these  results. 

All  observers  concur  in  the  opinion  that  the  prognosis  is  usually  favor- 
able. Recovery  may  occupy  several  weeks  or,  in  severe  cases,  six  months 
and  upwards,  according  to  the  intensity  and  extent  of  the  nervous  dis- 
order. Persistent  slowness  of  the  pulse  (less  than  forty  per  minute)  is  a 
serious  symptom. 

A  certain  number  of  cases  recover  under  the  use  of  ferruginous  prepa- 
rations, fresh  air,  nutritious  diet,  and  baths. 

When  the  paralysis  continues  for  a  long  time,  good  effects  may  be  ob- 
tained from  subcutaneous  injections  of  strychnine  (five  milligrammes  to 
one  centigramme  daily),  from  local  faradization,  and  from  galvanic  stimula- 
tion of  the  nerves.  But  we  should  not  wait  too  long  before  beginning  the 
use  of  electricity.  Good  results  are  also  obtained  by  methodical  hydro- 
therapeutics  and  sea-baths. 


DISEASES    OF   THE    NERVOUS    SYSTEM.  151 


CHAPTER  XXXIX. 

AN^^MIC    AND    REFLEX    PARALYSIS. 

We  shall  now  devote  our  attention  to  the  consideration  of  those  paral- 
yses in  which  the  motor  action  of  the  nerve-centres  is  interfered  with  by  a 
general  weakness  of  the  organism  and  a  morbid  insufficiency  of  the  afflux 
of  blood  (essential  anaemic  paralysis).  We  shall  then  discuss  those  cases 
in  which  a  circumscribed  arrest  of  the  circulation  produces  local  disturb- 
ances of  motion  (local  anaemic  or  ischaemic  paralysis);  finally,  we  shall 
refer  to  the  so-called  reflex  paralyses. 

A. — Anemic  axd  Ischemic  Paralysis. 

The  qualitative  changes  in  the  blood  which  are  left  over  by  severe 
general  diseases  often  exercise  a  disastrous  influence  upon  the  motor 
functions  of  the  nerve-centres.  Important  modifications  of  the  blood, 
consisting  in  a  diminution  of  the  red  globules  and  an  increase  in  the 
amount  of  water,  may  give  rise  to  those  forms  of  anjemic  paralysis  which 
are  observed  after  many  chronic  diseases,  such  as  profuse  diarrhoea, 
dysentery,  scorbutus,  metrorrhagia,  intestinal  hemorrhages,  hematuria, 
diabetes,  intense  chlorosis,  severe  intermittent  fevers,  and  various  cachexia?. 
In  these  cases  walking  is  rendered  difficult,  and  becomes  altogether  im- 
possible towards  the  end.  The  temperature  of  the  limbs,  the  paralysis  of 
which  is  almost  always  incomplete,  is  lowered  and  the  electro-muscular  con- 
tractility is  diminished.  Nevertheless,  movements  can  be  partially  per- 
formed while  the  patient  is  lying  in  bed,  and  the  bladder  and  rectum 
preserve  their  functions. 

In  ischfemic  paralysis  the  motor  and  sensory  disorders  are  caused  by 
a  partial  or  complete  suspension  of  the  afflux  of  arterial  blood.  The  first 
experiments  in  this  direction  were  performed  by  Stenson  (Elem.  Myolog. 
Specimen,  Flor.,  1667).  By  compressing  or  ligaturing  the  abdominal  aorta 
in  rabbits  below  the  renal  arteries,  he  produced  complete  paraplegia  of 
the  posterior  limbs,  which  disappeared  after  a  certain  period  if  the  com- 
pression was  not  maintained  for  too  long  a  time.  According  to  Longet, 
Stannius,  SchifE,  Kuehne,  Vulpian,  and  especially  according  to  the  ex- 
periments of  Schiffer  (Centralbl.,  37  and  38,  1869),  the  paraplegia  and 
anaesthesia  obtained  in  Stenson's  experiments  were  due  to  spinal  anfemia 
from  obliteration  of  the  spinal  branches  of  the  lumbar  arteries.  The 
irritability  of  the  nerves  diminishes  from  the  centre  to  the  periphery,  as 
does  the  electro-muscular  contractility,  though  the  latter  is  retained  for  a 
much  longer  period. 

Barth  has  reported  a  case  of  ischaemic  paraplegia  in  a  woman  fifty 
years  of  age  (Arch,  gen.,  1835).  At  the  autopsy  the  aorta,  below  the 
origin  of  the  renal  arteries,  was  found  to  be  obliterated  by  a  solid  clot. 
In  Gull's  patient  (Dublin  Quarterly  Journ.,  1856),  who  suffered  from  para- 
plegia and  anaesthesia  of  sudden  origin,  together  with  paralysis  of  the 
sphincters,  no  pulsation  could  be  detected  in  the  abdominal  aorta  and  in 


152  CLINICAL   TREATISE    ON 

the  arteries  of  the  lower  limbs,  but  the  mammary  arteries  were  found  to 
be  dilated.  During  the  following  months,  collateral  circulation  became 
established  through  the  thoracic  and  abdominal  vessels  and  the  motor 
power  improved,  though  the  pulsations  were  still  absent  in  the  abdominal 
aorta  and  its  branches.  Paralysis,  confined  to  certain  limbs  from  oblitera- 
tion or  compression  of  their  arterial  trunks,  is  much  more  frequently 
observed.  The  intermittent  character  of  these  paralyses  is  due  to  the  in- 
sufficiency in  the  supply  of  blood  and  to  the  fact  that  the  nerves  are 
readily  exhausted.  Thus,  Charcot's  patient  (Gaz.  Med.,  1859)  had  an 
attack  of  paralysis  of  the  right  leg  after  having  walked  a  short  distance, 
and  the  paralysis  always  disappeared  during  repose.  At  the  autopsy  an 
aneurism  was  found  in  the  right  primary  iliac,  with  fibrous  transfor- 
mation of  the  lower  third  of  the  vessel,  and  considerable  narrowing  of  the 
corresponding  branches.  Frerichs  also  published  an  analogous  case  (with- 
out autopsy). 

In  the  experiments  on  rabbits,  to  which  I  have  previously  referred 
(compression  of  the  iliac  and  crural  arteries  of  one  side,  in  curarized  or 
merely  narcotized  animals),  muscular  rigidity  occurred,  and  I  also  observed, 
after  resorting  to  electro-puncture,  a  gradual  diminution  of  farado-galvanic 
tnusoular  excitability,  advancing  to  complete  abolition  (at  the  end  of  about 
two  hours).  When  the  compression  of  the  arteries  was  interrupted,  the  ex- 
citability of  the  muscles  to  both  currents  was  gradually  re-established.  If 
we  cease  to  perform  artificial  respiration  in  the  curarized  animal,  the 
electro-muscular  contractility  will  disappear  more  rapidly  in  the  limb 
which  is  deprived  of  blood  than  in  its  fellow,  the  nutrition  of  which  is  main- 
tained for  a  much  longer  period  by  the  current  of  blood.  As  a  sequel  to 
these  experiments,  I  will  here  give  the  principal  symptoms  of  a  case  of 
ischremic  paralysis  of  the  left  leg  with  rapid  disappearance  of  the  galvanic 
excitability,  due  to  an  aneurism  of  the  left  crural  artery. 

A  man,  set.  fifty  years,  stated  that  on  October  31,  1869,  he  was  suddenly  seized, 
while  walking,  with  a  violent  pain  in  the  left  leg,  rendering  motion  impossible,  and  ne- 
cessitating the  removal  of  the  patient,  on  the  following  day,  to  the  Vienna  General  Hos- 
pital. Upon  examination,  a  solid  tumor  was  found  in  the  region  of  the  left  obturator 
foramen,  a  little  larger  than  a  chestnut,  pulsating  isochronously  with  the  crural  artery, 
and  presenting  no  bruit  on  auscultation. 

Two  days  afterwards  I  found  the  left  thigh  much  colder  than  the  right,  the  move- 
ments of  extension  scarcely  appreciable,  and  the  electro-muscular  contractility  and 
sensibility  considerably  diminished  in  the  extensors  of  the  thigh  (upon  comparison  with 
the  corresponding  muscles  on  the  healthy  side).  Upon  November  8d  (four  days  after 
the  beginning  of  the  disease)  the  electro-muscular  contractility  to  faradism  was  found 
to  be  abolished  on  the  anterior  surface  of  the  thigh.  Gangrene  of  the  limb  then  set  in, 
followed  by  chills,  and  the  patient  died  on  November  24th. 

Upon  autopsy,  a  sacculated  aneurism,  as  large  as  a  walnut,  was  found  in  the  neigh- 
borhood of  the  obturator  foramen.  It  originated  from  the  posterior  surface  of  the 
left  crural  artery,  pushed  the  vessel  upwards,  and  opened  into  its  lumen  by  an  ellip- 
tical opening  as  large  as  a  coffee-bean.  The  wall  of  the  artery  was  thickened  around 
this  opening,  and,  on  account  of  the  strong  tension  existing  above  the  neck  of  the 
aneurism,  the  calibre  of  the  artery  was  narrowed  to  such  an  extent  that  it  only  per- 
mitted the  passage  of  a  small-sized  sound.  The  deep  femoral  artery  and  the  point  of 
emergence  of  the  popliteal  artery  were  obliterated  by  solid,  adherent  thrombi. 

B. — Reflex  Paralysis. 

The  reflex  paralyses  which  are  observed  in^  diseases  of  the  digestive 
canal,  uterus,  and  urinary  passages  (Leroy  d'EtioUes)  are,  according  to 
Romberg,  Stanley,  and  Graves,  motor  spinal  paralyses,  due  to  a  suspen- 
sion of  the  sensory  influence  of  the  fibres  of  the  sympathetic  system.     Ac- 


DISEASES    OF   THE    NERVOUS    SYSTEM.  153 

cording  to  Brown-Sequard,  they  result  from  chronic  irritation  of  the  genito- 
urinary organs  with  secondary  contraction  of  the  vessels  of  the  cord  and 
atrophy  of  the  corresponding  parts.  In  support  of  his  opinion,  Romberg  re- 
fers to  the  experiments  of  Comhaire,  who  has  observed,  after  extirpation  of 
a  kidney  in  dogs,  a  paresis  of  the  corresponding  posterior  limb.  Gull  calls 
attention  to  the  importance  of  the  nervous  lesions  which  are  always  pres- 
ent in  these  experiments;  he  has  also  observed  that  the  paraplegia  almost 
always  occurs  in  chronic  cases,  after  the  innervation  of  the  mucous  mem- 
branes has  been  lowered.  In  his  opinion  the  paralyses  in  question  result 
from  the  propagation  of  the  inflammation  of  the  urinary  passages  to  the 
spinal  cord.  Remak  regards  these  affections  as  sacro-lumbar  neuritides. 
Finally,  Jaccoud  has  expressed  the  opinion  that  the  irritation  of  the  in- 
flamed bladder  produces  exhaustion  of  the  spinal  centres,  but  he  presents 
no  physiological  or  pathological  considerations  in  support  of  this  opinion. 

Levisson  has  been  more  fortunate  in  his  experimental  demonstrations 
(Reichert  and  Dubois-Reymond's  Arch.,  1869).  He  found  that  compres- 
sion of  the  uterus,  kidneys,  intestines,  or  bladder  produced,  in  addition 
to  abolition  of  reflex  excitability,  a  paralysis  of  the  posterior  limbs  which 
persisted  during  the  continuance  of  the  traumatism,  and  disappeared 
after  the  latter  had  ceased  to  act.  This  paralysis  was  due  to  an  arrest 
of  the  functions  of  the  motor  nerve-centres,  in  consequence  of  excessive 
irritation  of  the  sensory  fibres. 

While  these  experiments  demonstrate  that  peripheral  irritation  of  the 
nerves  may  temporarily  suspend  the  functions  of  the  cord  (conduction 
and  reflex  action),  Tiesler's  and  Feinberg's  investigations  have  shown 
that  violent  peripheral  irritation  may  be  propagated  to  the  cord  and  in- 
volve the  latter  in  the  morbid  process.  By  cauterizing  the  sciatic  nerve 
in  rabbits,  Tiesler  (Ueber  Neuritis,  Diss.,  Koenigsberg,  18G9)  was  able 
to  produce  paraplegia,  terminating  in  death  after  a  few  days.  At  the 
autopsy  a  foyer  of  inflammation  was  found  at  the  cauterized  spot  and  a 
second  one  in  the  cord,  corresponding  to  the  point  of  entrance  of  the  roots 
of  the  sciatic  nerve. 

In  animals  that  have  received  a  coating  of  varnish  and  who  suffer,  in 
consequence,  from  tremor,  hypernesthesia,  partial  anaesthesia,  increased 
reflex  action,  spasms,  and  paralysis,  Feinberg  has  observed  (Centralbl., 
35,  1873),  in  addition  to  dilatation  of  the  cutaneous  vessels,  of  the  capilla- 
ries of  the  lung  and  the  ramifications  of  the  vena  porta,  hyperaemia  of  the 
meninges,  and  a  dusky  redness  of  the  cervical  cord  (capillary  apoplexies). 
If  the  animals  survive  for  a  certain  length  of  time,  proliferation  of  the  neu- 
roglia occurs  with  atrophy  of  the  nerve-tubes  from  compression.  Thus 
the  irritation  of  the  cutaneous  nerves  produces  a  reflex  paralysis  of  the 
centres  of  vascular  innervation  in  the  cord. 

If  we  carefully  examine  the  medical  literature  of  the  subject  we  will 
find  that  a  large  number  of  cases  of  reflex  paralysis  were  associated  with 
material  lesions  in  the  cord. 

In  several  cases  (Fournier,  Mannkopf,  Feinberg)  tumors  were  found 
between  the  vertebras  and  spinal  meninges;  Gull's  cases  (paraplegia  fol- 
lowing cystitis  or  nephritis)  were  associated  with  spinal  meningitis,  soft- 
ening, and  atrophy  or  fatty  degeneration  of  a  portion  of  the  anterior 
columns.  In  Kussmaul's  case  of  paraplegia,  following  chronic  inflamma- 
tion of  the  urinary  passages  (Wuerzb.  Zeitschr.,  IV.  Bd.,  18G3),  there  was 
fatty  degeneration  of  the  nerve-fibres  in  both  sciatic  nerves,  with  athero- 
matous degeneration  of  the  arteries  of  the  pelvis.  In  another  case,  re- 
ported by  Kussmaul  and  Mayer  (Arch.  f.  klin.  Med.,  5.  H.,  1866),  the  paral- 


154    CLINICAL  TREATISE  ON  DISEASES  OF  THE  NERVOUS  SYSTEM. 

ysis  began  with  fever  and  nephritis,  and  rapidly  extended  to  all  the 
limbs,  with  acute  muscular  pains  and  insensibility  to  electrical  irritation. 
The  disease  was  due  to  a  periarteritis  nodosa  (thickening  and  nodosities 
in  a  very  large  number  of  arteries,  nuclear  and  abundant  cellular  prolifer- 
ation in  the  walls  of  the  vessels,  granular  or  fatty  degeneration  of  the 
muscles,  with  accumulation  of  fat  in  the  nerve-filaments  situated  around 
the  arterial  nodosities).  Leyden  (Diss.  Inaug.)  reported  three  cases  of 
paraplegia  following  affections  of  the  bladder,  which  were  character- 
ized in  the  beginning  by  symptoms  of  motor  and  sensory  irritation,  and 
later  by  paralysis.  Diffuse  softening  of  the  cord  was  found,  upon  au- 
topsy, in  two  of  these  cases. 

We  must  also  take  into  consideration  another  circumstance,  which 
usually  passes  unnoticed,  viz.:  that  an  affection  of  the  bladder  sometimes 
constitutes,  even  for  years,  the  sole  symptom  of  a  spinal  disease  which  is 
pursuing  a  latent  course. 

In  several  cases  which  were  referred  to  me  by  Prof.  Dittel,  explora- 
tion of  the  bladder  had  given  negative  results,  while  a  careful  examina- 
tion of  motion  and  sensation  showed  a  diminution  or  abolition  of  the  vari- 
ous forms  of  sensibility  in  the  legs;  in  the  trunk  there  was  abnormal  ex- 
citability of  the  nerve-trunks  or  of  the  genital  organs,  etc.  Often,  in 
cases  of  this  nature,  the  spinal  symptoms  are  only  manifested  after  the 
lapse  of  a  long  period.  It  is  very  probable  that  many  cases  of  central 
myelitis,  running  a  slow  course,  have  been  regarded  as  reflex  paralyses,  es- 
pecially when  no  characteristic  changes  were  found  upon  microscopical 
examination  of  the  cord. 

Levisson's  hypothesis  of  reflex  paralysis  is  only  applicable  in  rare  in- 
stances. Thus,  Echeverria  reports  the  history  of  a  patient  (Amer.  Med. 
Times,  1863),  suffering  from  anteversion  and  ulceration  of  the  cervix  uteri, 
in  whom  he  applied  a  weak  galvanic  current,  one  electrode  being  placed 
upon  the  symphysis  pubis  and  the  other  upon  the  cervix  uteri.  This  pro- 
cedure gave  rise  to  violent  pains  and  tremors  in  the  legs,  which  were 
completely  paralyzed  for  four  hours;  the  paralysis  disappeared  entirely 
after  the  lapse  of  fourteen  hours. 

In  a  case  published  by  Nonat,  loss  of  consciousness  and  paraplegia 
were  caused  by  cauterization  of  the  cervix  uteri. 

In  Landry's  patient,  the  paralysis  disappeared  after  restoration  of  the 
deflected  uterus.  I  have  published  the  case  of  a  girl,  set.  twenty-three 
years,  who  suffered,  for  three  weeks,  from  paresis  of  the  legs,  coming  on 
after  pains  and  cramps  in  the  abdomen.  Upon  examination  I  found  a 
needle  deeply  imbedded  in  the  vagina,  and  the  paresis  rapidly  disappeared 
after  the  removal  of  the  foreign  body. 

From  the  preceding  remarks  it  is  very  evident  that  the  class  of  reflex 
paralyses  will  diminish  more  and  more,  in  proportion  as  the  doubtful  cases 
are  more  carefully  examined.  Functional  reflex  paralyses  constitute  very 
rare  exceptions. 

We  need  merely  state  with  regard  to  the  treatment  of  reflex  paralysis, 
that  especial  attention  must  be  paid  to  the  primary  disease.  We  may  re- 
sort, according  to  circumstances,  to  iodine  treatment,  baths,  hydrothera- 
peutics,  or  to  galvanism  (the  current  being  directed  from  the  vertebral 
column  to  the  nerves  of  the  affected  limbs).  After  having  relieved  the 
pains,  we  should  endeavor  to  improve  the  power  of  motion.  The  constant 
current  is  recommended  in  the  treatment  of  the  existing  neuritis  (in  affec- 
tions of  the  bladder,  Leyden  thinks  that  a  sacro-lumbar  neuritis  may  be 
propagated  to  the  cord). 


CLASS     VIII. 


NEUROSES  OF  THE  SEXUAL  APPARATUS. 


CHAPTER  XL. 
A. — Seminal  Losses. 


The  term  spermatorrhoea  usually  includes  all  involuntary  discbarges  of 
semen,  occurring  genersliy  in  the  day-time  and  without  previous  erection. 
But  more  careful  observation  has  shown  that  true  spermatic  fluxes  (the 
excreted  fluid  containing  spermatozoids)  are  exceedingly  rare.  In  the 
majority  of  cases  the  so-called  seminal  losses  are  composed  of  prostatic, 
mucous  fluid,  the  emission  of  which  may  be  accompanied  by  voluptuous 
sensations.  In  patients  affected  in  this  manner,  a  moderate  action  of  the 
bulbo-cavernosus  muscle  will  suffice  to  produce  an  intermittent  discharge 
of  mucus  and  prostatic  fluid.  In  the  majority  of  patients  this  sperma- 
torrhoea is  merely  a  consequence  of  pollutions,  and  its  occurrence  is  at- 
tended with  an  incomplete  erection. 

As  a  rule,  involuntary  seminal  losses  occur  at  night,  during  a  state  of 
more  or  less  complete  erection,  and  are  then  known  as  pollutions.  The 
most  frequent  etiological  factors  are:  masturbation  during  childhood  and 
youth  (especially  in  patients  who  are  naturally  very  excitable),  erotic 
thoughts  (obscene  books  or  pictures),  and  over-excitement  of  the  genital 
system  from  excessive  venery.  In  many  cases  the  affection  is  due  to 
anatomical  lesions  and  functional  disorders.  In  habitual  constipation 
the  evacuation  of  hard  fecal  matter  is  often  accompanied  by  a  loss  of 
semen  (recognizable  with  the  microscope),  leaving  after  it  a  disagreeable 
sensation  in  the  urethra,  which  often  lasts  more  than  an  hour. 

Diseases  of  the  rectum  (haemorrhoids,  abundant  oxyuri,  as  I  have  ob- 
served in  two  cases),  diseases  of  the  bladder  (calculus,  catarrh),  of  the 
seminal  vesicles,  of  the  prostate,  of  the  urethra  (blenorrhagia),  and  of  the 
glans  (herpes,  phimosis,  accumulation  of  sebum)  may  also  give  rise  to 
pollutions. 

Finally,  certain  irritative  conditions  of  the  cord  are  accompanied  by 
frequent  pollutions.  Although  we  do  not  agree  with  Tissot,  who  regards 
all  patients  suffering  from  pollutions  as  threatened  by  insanity,  amauro- 
sis, impotence,  and  ataxia,  we  nevertheless  recognize  the  fact  that  fre- 
quent seminal  losses,  continued  for  several  years,  are  not  without  danger, 
as  denoting  a  diminution  in  the  energy  of  the  spinal  nervous  system.    We 


156  CLINICAL   TREATISE    OTT 

have  entered  into  this  question  more  in  detail  in  the  remarks  on  the  eti- 
ology of  ataxia  (Vol.  I.,  p.  245). 

Infrequent  pollutions,  which  have  no  effect  upon  the  vital  energies 
and  upon  nutrition,  may  disappear  spontaneously  upon  regulating  coitus 
and  the  habits  of  life.  But  seminal  losses  which,  by  their  frequency,  rap- 
idly debilitate  the  organism  during  youth  and  continue  for  years,  may 
finally  exhaust  the  nervous  system,  affect  its  power  of  resistance  to  ex- 
ternal influences,  lead  to  hypochondria  and  to  marked  intellectual  weak- 
ness, and  very  frequently  act  as  the  cause  of  spinal  affections.  The  pol- 
lutions of  the  stage  of  irritation  in  ataxia  are  usually  accompanied  by 
other  characteristic  signs,  such  as  frequent  neuralgia  (especially  sciatic), 
temporary  diplopia,  weakness  of  the  efforts  at  coitus,  and  increased  elec- 
trical excitability. 

In  the  treatment  of  pollutions  we  must  especially  endeavor  to  remove 
their  cause.  When  due  to  haemorrhoids,  habitual  constipation,  and 
oxyuri  in  the  rectum,  we  should  prescribe  injections  of  cold  water  or 
vinegar,  or  a  weak  solution  of  corrosive  sublimate.  No  less  importance 
must  be  attached  to  the  regulation  of  the  habits  of  life  of  the  patients. 
Physical  exercise  and  a  moderate  amount  of  mental  labor  are  indicated  in 
order  to  maintain  the  vigor  of  the  body,  and  to  prevent  erotic  dreams. 
The  diet  should  be  nutritious,  to  the  exclusion  of  fatty,  spiced  food,  and 
of  stimulating  drinks.  At  night  the  patient  should  merely  take  a  little 
milk  or  an  ice,  and  should  drink  very  sparingly,  since  fulness  of  the  blad- 
der is  apt  to  produce  erections.  The  patient  should  sleep  upon  a  hard 
mattress  and  pillow,  be  lightly  covered,  and  not  assume  the  dorsal  decu- 
bitus; he  should  not  sleep  too  long,  and  must  avoid  taking  a  siesta 
during  the  day. 

Among  the  internal  remedies,  quinine  and  iron  are  useful  in  anaemic 
subjects.  Camphor,  lupulin  (two  to  four  decigrammes  morning  and  even- 
ing), and  bromide  of  potassium  (two  to  three  grammes  daily)  have  a 
sedative  effect  upon  the  erections;  daturine  is  a  costly  and  uncertain 
preparation.  Good  effects  are  also  obtained  from  belladonna  (adminis- 
tered in  the  form  of  extract,  internally  or  in  suppositories)  and  atropine 
(the  dose  being  cautiously  increased).  Fowler's  solution  is  an  excellent 
sedative  of  the  genital  functions.  It  may  be  given  for  a  long  time,  in 
doses  of  five  to  ten  drops  upon  a  lump  of  sugax,  before  going  to  bed.  I 
have  also  obtained  good  results  from  this  remedy  in  priapism. 

Lallemand  recommended  cauterization  of  the  prostatic  portion  of  the 
urethra  by  means  of  a  stick  of  nitrate  of  silver,  concealed  in  a  catheter. 
Two  or  three  cauterizations,  repeated  after  an  interval  of  two  or  three 
weeks,  are  said  to  cause  the  disappearance  of  the  disease  in  the  majority 
of  cases.  Dittel  (of  Vienna)  recommends  a  less  painful  and  more  cer- 
tain remedy,  consisting  of  the  introduction  with  the  caustic  holder  (as  far 
as  the  prostatic  region)  of  a  urethral  suppository  of  butter  of  cacao  and 
nitrate  of  silver  (eight  to  twelve  milligrammes),  its  position  being  deter- 
mined by  the  rectal  touch.  "\Ve  may  also  resort  to  the  intermittent  in- 
troduction of  elastic  or  wax  bougies,  coated  ^^ith  belladonna  ointment,  or 
of  steel  sounds.     The  urethral  canal  is  almost  always  hyperaesthetic. 

Hydrotherapeutic  treatment  furnishes  the  most  prompt  and  efficient 
means  of  arresting  pollutions  at  the  beginning  of  the  affection.  The 
beneficial  effects  of  cold  sponging  of  the  entire  body  (with  the  exception 
of  the  genital  organs)  have  been  recognized  for  a  long  time.  Even  more 
permanent  effects  are  obtained  from  sitz-baths  of  short  duration,  taken 
in  the  morning,  and  followed  by  moist  frictions.     These  are  afterwards 


DISEASES    OF   THE    NERVOUS    SYSTEM.  157 

combined  with  cool  half-baths,  dorsal  affusions,  and  slight  douches  to  the 
perineum  or  lumbar  region.  In  employing  electrical  treatment,  the  anode 
of  a  battery  of  moderate  strength  is  placed  upon  the  lumbar  region,  and 
the  cathode  is  applied  for  three  or  four  minutes  along  the  spermatic  cord, 
'  the  perineum,  and  penis.    Too  prolonged  or  frequent  sittings  are  injurious. 


B. lilPOTENCE. 

The  inability  to  perform  coitus  with  sufficient  frequency  or  energy  is 
commonly  termed  impotence.  The  physiological  capacity  for  indulging 
in  sexual  intercourse  varies  greatly  according  to  the  individual,  in  the 
same  manner  that  hunger,  thirst,  sleep,  and  muscular  power  vary.  It 
depends  upon  the  condition  of  the  physical  powers,  the  manner  of  life, 
and  the  force  of  habit. 

I  have  recently  had  occasion  to  observe  the  influence  of  habit  upon  sexual  inner- 
vation. A  man,  who  was  married  to  a  young  and  pretty  woman,  was  compelled  to 
abstain  from  sexual  intercourse  for  a  period  of  eight  months,  on  account  of  the  ill- 
ness of  his  wife.  After  her  recovery,  he  was  unable  to  accomplish  the  sexual  act  with 
his  wife,  though  his  love  for  her  had  not  changed,  and  he  experienced  no  diflBculty  in 
having  intercourse  with  other  women,  who  were  older  and  less  attractive.  In  her 
presence  he  could  only  obtain  an  erection  by  imagining  himself  in  company  with  an- 
other woman;  he  could  then  begin  intercourse,  but  ejaculation  never  followed,  al- 
though the  act  could  be  performed  completely  with  others. 

Impotence,  especially  in  large  cities,  is  very  often  due  to  long-con- 
tinued onanism  or  to  excesses  in  venere  et  haccho.  In  much  rarer  in- 
stances it  is  symptomatic  of  a  central  affection.  When  masturbation 
has  not  been  practised  too  long  and  too  often,  sexual  impotence  may  be 
usually  attributed  to  the  absence  of  desire  for  natural  coitus.  Young 
men,  who  are  warned  in  time  of  the  danger  of  their  evil  habits,  may  re- 
cover their  natural  desire  by  frequenting  female  society,  and  may  be 
completely  restored  by  an  early  marriage.  We  may  also  hope  for  a 
favorable  recovery  when,  after  practising  masturbation  to  a  moderate  ex- 
tent, the  young  men,  who  are  otherwise  healthy,  only  have  incomplete 
erections  when  they  attempt  intercourse,  and  are  therefore  discouraged 
from  any  further  attempts.  In  these  cases  we  may  restore  the  physical 
and  mental  tone  of  the  patient  by  appropriate  hydrotherapeutic  and 
electrical  treatment.  The  most  serious  cases  are  those  in  which  the  pa- 
tients have  practised  masturbation  from  childhood  or  puberty,  in  whom 
the  physical  and  moral  tone  is  very  low,  and  who  only  have  infrequent 
and  incomplete  erections.  The  prognosis  is  then  grave  as  regards  the 
restoration  of  the  genital  functions,  but  is  not  absolutely  unfavorable  in 
young  patients. 

In  the  impotence  which  follows  sexual  excesses  and  obstinate  pollu- 
tions, the  sexual  desire  is  often  more  intense  than  in  the  normal  condi- 
tion, but  the  erections  are  incomplete,  and  the  ejaculation  of  semen  is 
almost  always  precipitate.  In  old  cases  the  skin  of  the  glans  and  scro- 
tum is  pale,  flabby,  often  traversed  by  varicose  dilatations,  cold,  and  not 
sensitive  to  touch;  the  penis  is  flaccid  and  retracted,  and  the  testicles 
are  soft  and  do  not  present  their  normal  sensibility  to  pressure.  After 
these  patients  have  attained  a  certain  age,  they  are  rarely  susceptible  of 
improvement. 


158  CLINICAL   TREATISE    ON 

Finally,  impotence  may  be  symptomatic  of  diseases  of  the  spinal  cord. 
In  some  cases  weakness  of  the  genital  functions  is  the  first  indication  of 
incipient  ataxia.  Rapid  diminution  of  the  virile  power  in  a  patient  in 
the  prime  of  life  should  awaken  serious  apprehensions  in  the  mind  of  the 
physician.  The  medical  attendant  should  not  regard  this  symptom  as 
unimportant,  but  should  place  his  patient  under  prolonged  hydrothera- 
peutic  and  electrical  treatment,  and  should  advise  him  to  husband  his 
powers,  especially  if  he  presents  an  hereditary  neuropathic  tendency. 

In  many  cases  long-continued  pollutions,  which  were  at  first  accom- 
panied by  increase  of  sexual  desire,  finally  terminate  in  impotence  and  in 
the  developmont  of  spinal  symptoms.  The  irritative  symptoms  which 
frequently  appear  after  exposure  or  extreme  fatigue  (vague  neuralgia, 
sciatica,  temporary  diplopia,  frequent  erections  or  pollutions  during  the 
night)  are  often  accompanied  by  an  early  abolition  of  the  virile  power.  The 
latter  is  manifested  by  premature  ejaculation,  incomplete  erections,  or  by 
temporary,  intermittent  impotence,  and  often  terminates  in  suppression 
of  voluptuous  sensations  and  complete  extinction  of  the  sexual  func- 
tions. 

From  the  preceding  remarks  it  is  evidently  of  the  highest  importance 
that  we  determine  whether  the  impotence  is  due  to  sexual  excesses,  to 
moral  depression,  or  whether  it  constitutes  the  initial  symptom  of  an  af- 
fection of  the  spinal  cord.  The  physician  is  often  consulted  by  this  class 
of  patients  with  regard  to  the  advisability  of  marriage. 

In  patients  belonging  to  the  first  category,  marriage  with  a  person  of 
calm  temperament  may  be  permitted,  after  the  impotence  has  undergone 
marked  improvement.  Matrimony  should  be  strenuously  opposed,  how- 
ever, in  those  patients  who  present  spinal  symptoms. 

In  the  treatment  of  impotence,  electricity  and  hydrotherapeutics  fur- 
nish the  most  efficient  remedies.  In  the  electrical  treatment  a  constant 
current  is  at  first  passed  through  the  vertebral  column  (five  minutes). 
The  cathode  is  then  placed  over  the  perineum,  spermatic  cord,  testicles, 
and  dorsum  penis  (six  to  eight  minutes),  the  anode  being  applied  to  the 
lumbar  region.  The  sittings  should  at  first  be  held  every  other  day,  and 
then  daily  (six  to  eight  weeks).  If  a  sensation  of  cold  and  numbness  is 
experienced  in  the  penis,  the  electrical  brush  may  be  applied  to  the  glans 
and  dorsum  penis,  and  the  corpora  cavernosa  may  be  stimulated  by  means 
of  a  moist  electrode.  Duchenne  resorts  to  the  introduction  of  an  elec- 
trode into  the  urethra  as  far  as  the  veru  montanum,  the  other  moist 
electrode  resting  on  the  perineum.  The  employment  of  this  measure,  as 
well  as  faradic  stimulation  of  the  testicles,  demand  great  care,  as  their 
excessive  use  may  lead  to  neuralgias.  Hydrotherapeutic  treatment  must 
be  regulated  according  to  the  condition  of  the  patient.  In  the  impo- 
tence which  is  due  to  excesses  and  moral  causes,  we  may  employ  long- 
continued  moist  packs  (continued  until  the  return  of  sufficient  warmth  to 
the  body),  followed  by  half-baths,  full-baths,  and  by  daily  douches  to  the 
sacrum  and  perineum.  In  some  cases  I  have  obtained  considerable  bene- 
fit by  combining  hydrotherapeutics  and  electricity.  In  weak,  timid  pa- 
tients, and  in  those  who  present  symptoms  of  irritation  of  the  cord,  we 
may  prescribe  moist  frictions  (with  a  cloth  dipped  in  water  at  18°-30° 
C.)^  followed  by  cool  half-baths  and  dorsal  affusions.  Gold  water,  douches, 
and  full-baths  must  not  be  employed  on  account  of  their  stimulating 
action. 


DISEASES    OF   THE    NERVOUS    SYSTEM.  159 


C. ASPEBMATISM. 

The  term  aspermatism  refers  to  that  morbid  condition  in  which  erec- 
tion and  even  voluptuous  sensations  are  produced  without  the  ejacula- 
tion of  semen.  This  affection,  which  presents  very  remarkable  peculiari- 
ties, may  be  produced  by  various  pathological  changes. 

The  absence  of  ejaculation  during  coitus  may  be  due  to  prolonged 
masturbation,  as  in  Cosmano-Dumenez's  case  (Gaz.  med.  de  Paris,  17-19, 
1863).  When  the  seminal  passages  are  in  a  condition  of  atony,  they  re- 
spond with  more  difficulty  to  cerebral  influences  than  to  the  spinal  re- 
flexes produced  by  onanism.  The  differences  which  may  occur  in  cere- 
bral innervation  are  evident  from  Hieguet's  observations  (Bullet,  de 
I'Acad.  roy.  de  Belgique,  II.,  1861),  in  which  the  emission  of  semen  did 
not  occur  during  coitus,  but  only  during  erotic  dreams.  In  Schmitt's 
case  ( Wuerzb.  Zeitschr.,  III.  Bd.,  p.  361-366),  emission  of  semen  occurred 
neither  during  coitus  nor  in  pollutions  ;  nevertheless  the  patient  experi- 
enced, as  in  the  normal  condition,  voluptuous  sensations  and  a  feeling  of 
exhaustion  after  the  performance  of  coitus.  In  this  patient  both  duct, 
ejaculat.  were  supposed  to  open  in  common  into  the  obliterated  vesicula 
prostatica. 

Gosselin  was  one  of  the  first  who  carefully  investigated  the  patho- 
logical conditions  present  in  obliteration  of  the  seminal  passages  (x\rch, 
gen.,  Sept.,  1853).  According  to  this  author  the  obliteration  may  occur 
in  the  efferent  canals  or  in  the  tail  of  the  epididymis,  thus  causing  an  ob- 
struction to  the  passage  of  semen  into  the  seminal  vesicles  (obstructions 
in  the  head  of  the  epididymis  have  no  effect  upon  the  course  of  the 
semen) ;  finally,  there  may  be  partial  or  total  obliterations  in  the  seminifer- 
ous tubes  of  the  testicles.  Unfortunately,  Gosselin  has  not  mentioned 
whether  all  the  patients  who  were  affected  with  these  anomalies  also 
suffered  from  aspermatism. 

Atrophy  of  both  testes,  tubercular  and  cheesy  degeneration  of  the 
epididymis,  bilateral  cryptorchism,  congenital  absence  of  the  efferent 
canals  (observations  by  Gosselin  and  J.  Hunter),  considerable  hypertro- 
phy of  the  prostate,  especially  inflammations  and  abscesses  in  the  neigh- 
borhood of  the  prostate,  and  narrow  urethral  strictures  (Petit)  may  also 
act  as  causes  of  aspermatism.  In  one  case,  reported  by  Lapeyronie  (as- 
permatism after  recovery  from  blenorrhagia),  the  emission  of  semen  only 
occurred  after  the  erection  had  subsided.  At  the  autopsy,  which  was 
performed  several  years  afterwards,  a  cicatrix  was  found  in  the  veru 
montanum,  which  was  directed  towards  the  bladder.  The  cicatricial  tis- 
sue had  changed  the  direction  of  the  ejaculatory  ducts  in  such  a  manner 
that  they  opened  towards  the  neck  of  the  bladder,  as  was  clearly  demon- 
strated by  an  injection  of  the  efferent  canals  and  seminal  vesicles. 

Demarquay's  patient,  who  had  received  a  gunshot  wound  of  the  blad- 
der and  rectum,  suffered  from  inflammation  and  atrophy  of  the  right  tes- 
ticle; upon  the  left  side  the  efferent  canal  and  seminal  vesicle  had  been 
involved  in  the  wound,  and  thus  gave  rise  to  aspermatism.  In  C.  Du- 
menez's  case  (large  abscess  from  contusion  of  the  perineum),  after  open- 
ing of  the  abscess  and  recovery,  the  penis  remained  dry  during  coitus, 
although  the  patient  experienced  the  sensation  produced  by  emission  of 
semen.  Microscopical  examination  of  the  urine  revealed  the  presence  of 
spermatozoids,  and  the  semen  must,  therefore,  have  been  discharged  into 
the   bladder.     Aspermatism   may   also  follow   bilateral  lithotomy,  when 


160    CLINICAL  TREATISE  ON  DISEASES  OF  THE  NERVOUS  SYSTEM. 

the  ejaculatory  ducts  have  been  cut,  or  when  their  direction  has  been 
changed  by  the  cicatrization  of  the  wound  of  the  bladder  and  the  semen 
is  discharged  into  the  latter  organ. 

Asperrnatism  is  not  ^jer  se  a  serious  affection,  but  it  may  become  so  in 
time  from  its  influence  on  the  mind.  The  patients  fall  into  a  profound 
melancholy,  shun  the  society  of  their  fellows,  and  may  finally  become  in- 
sane. In  Dumenez's  case,  which  was  referred  to  above,  the  patient  thought 
that  his  sex  had  been  changed,  and  wrote  long  letters  to  an  imaginary 
lover. 

The  treatment  of  aspermatism  is  very  rarely  successful.  Electricity 
(especially  the  introduction  of  an  electrode  as  far  as  the  veru  montanum) 
and  hydrotherapeutics  may  prove  useful,  as  shown  by  Vicquet's  observa- 
tion, in  atony  of  the  seminal  excretory  passages. 


CLASS    IX. 


DISEASES  OF  THE  PERIPHERAL  NERVOUS  SYSTEM. 


GENERAL  CHARACTERISTICS   OF  PERIPHERAL 
PARALYSIS. 

The  scope  of  peripheral  nervous  affections  comprises  the  various  mor- 
bid conditions  of  the  cerebral  and  spinal  nerves,  from  the  roots  and 
plexuses  to  the  prolongations  which  form  the  nerve-trunks  and  branches. 
In  various  parts  of  their  course  the  nerves  may  be  subjected  to  traumatic 
and  rheumatic  influences,  and  to  mechanical  violence  (compression,  rupture, 
concussion).  Complete  or  incomplete  paralysis  will  develop,  according  to 
the  intensity  of  the  exciting  cause.  The  inflammatory  changes  in  the 
muscles,  which  we  have  described  in  the  preceding  chapters  as  sequences 
of  acute  diseases,  may  also  give  rise  to  peripheral  paralysis. 

Lesions  of  the  anterior  nerve-roots  within  the  spinal  canal  (inflamma- 
tory affections,  atrophy  from  neoplasms)  produce  motor  paralysis  from  in- 
terference with  conduction.  In  affections  of  the  nerve-roots  beyond  the 
spinal  ganglia,  the  paralysis  usually  extends  to  the  domain  of  several 
nerves,  and  is  accompanied  by  corresponding  anfesthesia.  If  the  plexuses 
are  involved,  the  paralysis  occupies  a  greater  or  less  extent,  but  is  gener- 
ally limited  to  one  side  of  the  body.  It  appears,  for  example,  within  the 
territory  of  the  lumbar  plexus,  when  circumscribed  exudations  or  foci  of 
suppuration  are  present  in  the  pelvis.  Paraplegia  occurs  in  very  rare 
cases,  when  there  are  large  or  multiple  morbid  products  compressing  the 
lumbar  plexuses  or  the  nerves  of  the  cauda  equina  upon  both  sides.  A 
rapid  diminution  of  nutrition  and  electro-muscular  contractility  occurs 
along  the  course  of  the  affected  nerves. 

Paralysis  due  to  neuritis  may  result  from  a  compression  exercised  by 
the  meninges  upon  the  roots  composing  the  nerve-trunks,  from  inflamma- 
tory thickening  of  the  sheaths  of  the  nerves,  or  from  degeneration  of  the 
myeline.  The  paralyses  are  accompanied  by  intense  neuralgic  pains,  and 
are  attended,  when  the  neuritis  occurs  in  mixed  nerves,  by  disorders  of 
sensation,  muscular  atrophy,  diminution  of  electro-muscular  contractility, 
and  trophic  disturbances.  When  a  single  nerve-trunk  is  involved,  the 
paralysis  is  usually  limited  to  the  regions  dependent  on  this  nerve  and  to 
the  corresponding  groups  of  muscles.  In  peripheral  paralysis  the  electri- 
cal reactions  present  certain  characteristic  signs,  the  discovery  of  which 
has  shed  further  light  upon  the  interpretation  of  its  pathological  phenom- 

VOL.    II.— 11 


162  CLINICAL    TREATISE    ON 

ena.  The  manifestations  on  the  part  of  the  nerves  and  muscles,  under 
the  influence  of  electrical  stimulation,  vary  on  account  of  the  degenerative 
processes  which  are  present  in  the  beginning,  and  of  the  regeneration 
which  occurs  at  a  later  period.  Reserving  a  more  detailed  discussion  of 
the  electrical  phenomena  for  the  chapter  on  traumatic  paralysis,  we  will 
here  remark  that  the  irritability  of  the  nerves  to  both  currents  diminishes, 
and  finally  disappears  completely,  in  proportion  as  the  degeneration  pro- 
gresses from  the  centre  to  the  periphery  in  the  ramifications  of  the  nerves. 
When  recovery  occurs,  voluntary  motion  is  often  restored  before  the 
farado-galvanic  excitability  of  the  nerves.  On  the  part  of  the  muscles 
the  faradic  contractility  diminishes  early,  and  then  disappears  completely, 
while  the  galvanic  excitability  is  preserved  and  often  even  increased.  At 
a  later  period  the  latter  reaction  progressively  diminishes  in  proportion 
as  the  faradic  irritability  and  power  of  voluntary  motion  reappear  in  the 
paralyzed  muscles. 

Finally,  we  may  refer  to  the  frequent  complication  of  peripheral 
paralysis  with  vaso-motor  and  trophic  disorders.  The  initial  vascular 
dilatation  and  elevation  of  temperature  are  followed,  in  the  later  stages,  by 
retardation  of  the  circulation,  livid  discoloration  of  the  skin  and  lowering 
of  the  temperature.  The  trophic  disturbances  are  not  only  manifested 
by  considerable  atrophy  of  the  muscles,  but  they  also  appear  as  general  nu- 
tritive disorders,  atrophy  of  the  skin,  anomalies  of  secretion,  exanthemata, 
changes  in  the  epithelial  elements  and  in  the  joints.  Severe  disturbances 
of  nutrition,  such  as  gangrenous  ulcerations,  may  also  occur.  In  the 
chapter  on  traumatic  paralysis  we  shall  discuss,  in  detail,  the  nature  of 
these  nutritive  disorders  and  their  relations  with  the  trophic  centres  of 
the  cord. 


DISEASES    OF   THE    NERVOUS    SYSTEM.  163 


CHAPTER  XLI. 

RHEUMATIC  LESIONS  OF   THE  NERVES. 

Among  external  influences,  cold  and  cold  moisture  exercise  the  most 
deleterious  action  upon  the  nervous  system.  Eckhard,  J.  Rosenthal,  and 
Afanasieff  have  experimented  upon  the  action  of  various  grades  of  tem- 
perature on  the  nerves  of  frogs.  E.  H.  Weber  (Wagner's  Handwoer- 
terb.  d.  Phys.,  III.  Bd.)  studied  the  properties  of  the  cutaneous  nerves 
in  man,  in  his  excellent  work  on  the  sense  of  touch  and  general  sensi- 
bility. In  his  experiments  with  temperatures  ranging  below  zero,  the 
painful  sensations  were  found  to  present  great  differences,  even  in  por- 
tions of  the  skin  which  were  situated  very  close  to  one  another,  according 
to  the  irregularities  in  the  distribution  of  the  sensory  nerves  which  had 
been  subjected  to  the  action  of  the  cold. 

I  have  made  analogous  experiments  upon  the  action  of  cold  on  the 
motor  and  sensory  nerves  (Wien.  Med.  Halle,  18G4,  No.  1-4),  in  order  to 
determine  with  more  exactness  the  action  of  cold  upon  the  nerve-trunks. 
My  observations  referred  to  the  condition  of  sensation  and  motion,  to  the 
oscillations  in  the  temperature,  and  to  the  electrical  reactions  of  certain 
peripheral  regions  which  had  been  subjected  to  the  action  of  cold.  I 
have  made,  upon  my  own  person,  applications  of  ice  (two  to  four  min- 
utes) upon  the  nerves  of  the  arm  and  foot,  and  have  found  that  the  most 
marked  effects  were  produced  upon  the  ulnar  nerve.  The  thermometric 
measurements  were  made  in  the  second  and  fourth  interdigital  spaces, 
which  presented  the  same  temperature  before  the  experiment.  In  order 
to  give  a  concise  review  of  the  phenomena  observed  after  chilling  of  the 
nerve-trunks,  we  may  divide  them  into  three  categories,  according  as 
they  affect  sensation,  motion,  and  temperature. 

The  first  effect  of  the  application  of  ice  is  a  painful  exaggeration  of 
the  functions  of  the  sensory  nerve-fibres.  If  the  action  of  the  ice  is  pro- 
longed, this  phenomenon  gradually  disappears,  and  is  followed  by  a  dimi- 
nution in  the  excitability  of  the  nerve-fibres. 

The  motor  functions  of  the  muscles  at  first  manifest  an  increased 
excitability,  but  if  the  experiment  is  prolonged,  the  reaction  of  the  mus- 
cles becomes  weaker  and  weaker,  and  is,  finally,  almost  completely  sup- 
pressed (from  suspension  of  nervous  conduction).  At  the  beginning  of 
the  experiment  an  electrical  stimulus,  which  is  scarcely  perceived  under 
normal  conditions,  will  produce  muscular  contractions,  while,  in  the 
second  period,  the  excitability  and  motility  of  the  muscles  almost  entirely 
disappear. 

The  influence  of  applications  of  ice  upon  the  temperature  are  usually 
manifested,  in  the  beginning  of  the  experiment,  by  a  fall  of  temperature 
varying  from  0.5°-l°  C  In  rare  cases  this  fall  is  preceded  by  a  slight 
rise  of  temperature.  When  the  nervous  condition  is  more  seriously  dis- 
turbed, an  elevation  of  temperature  occurs  secondarily.  In  addition  to 
motor  paralysis,  the  inner  fingers  (when  the  ulnar  nerve  is  experimented 


164  CLIKICAL    TREATISE   ON" 

upon)  present  evidences  of  hyperjemia  (redness,  heat).  After  the  applica- 
tion of  cold  has  ceased,  quite  a  long  time  (forty  to  fifty  minutes)  elapses 
before  the  temperature  returns  to  the  normal. 

When  the  ulnar  nerve  is  paralyzed,  an  elevation  of  temperature  oc- 
curs in  the  inner  fingers  (from  34.4°-35.6°  C),  while  that  of  the  other 
fingers  is  considerably  reduced  (from  34.4°-27.7°  C).  The  elevation  of 
temperature  is  due  to  a  reflex  action  upon  the  vaso-motor  nerves  and  to 
the  increase  of  the  current  of  blood  in  the  dilated  vessels.  This  reflex 
paralysis  of  the  sympathetic  nerves  from  the  action  of  cold  appears  to 
me  to  present  a  great  analogy  to  the  symptoms  observed  by  CI.  Bernard 
and  Budge  after  section  of  the  cervical  sympathetic.  In  their  experi- 
ments the  temperature  of  the  ear  upon  the  side  of  the  section  was  in- 
creased, while  it  was  diminished  in  the  ear  upon  the  healthy  side.  These 
experimental  results,  which  were  afterwards  confirmed  by  Waller,  Eulen- 
burg,  and  Szymanowski,  are  also  applicable,  in  great  part,  to  pathological 
phenomena. 

With  regard  to  etiology,  experience  teaches  that  the  vast  mesh-work 
of  peripheral  nerves  is  most  threatened  with  danger  when  the  body, 
overheated  and  covered  with  an  abundant  perspiration,  is  suddenly  ex- 
posed to  the  action  of  cold,  or  quickly  passes  through  various  strata  of 
air  at  different  temperatures.  The  affections  which  are  caused  by  mois- 
ture or  cold  are  limited,  in  the  majority  of  cases,  to  small  spaces.  One 
of  the  upper  or  lower  limbs,  or  merely  a  portion  of  a  limb,  is  affected  by 
the  paralysis  which  I  have  called  paralysis  from  the  action  of  cold,  in 
order  to  distinguish  it  from  the  paralytic  form  which  is  commonly  termed 
rheumatic  and  which  does  not  present  the  symptoms  to  which  we  have  re- 
ferred. In  certain  cases,  paralysis  from  cold  may  cause  abolition  of 
sensation  throughout  a  large  part,  if  not  the  whole  of  the  integument  of 
the  body.  Binz  has  described,  under  the  term  generalized  peripheral 
anfesthesia,  a  case  of  this  kind  in  a  young  woman  who  had  fallen  asleep 
before  an  open  window.  In  addition  to  cutaneous  antesthesia,  all  the 
mucous  membranes  (even  that  of  the  vagina)  v.'ere  insensible  to  the  prick 
of  a  pin;  taste  and  smell  were  likewise  abolished.  Recovery  occurred, 
after  the  lapse  of  a  week,  from  the  application  of  frictions  to  the  entire 
body.  In  Worms'  case,  a  soldier,  who  was  overheated  from  running,  was 
exposed  to  a  draught  of  air;  one  of  the  legs  at  first  became  numb,  the 
next  day  the  other,  the  third  day  the  trunk  became  insensible,  and,  on 
the  fifth  day,  speech  was  embarrassed.  This  was  afterwards  followed  by 
anfesthesia  of  the  entire  surface  of  the  body,  analgesia  of  the  feet  and 
mucous  membranes,  and  anaphrodisia.  This  condition  continued  for  five 
days,  and  disappeared  completely  after  the  employment  of  vapor- baths 
and  electricity.  Romberg,  Mayer,  Kaulich,  Griffith,  and  Christophers 
have  also  observed  sensory  disorders  due  to  the  action  of  cold,  extending 
over  larger  or  small  areas,  and  involving  motion  to  a  greater  or  lesser 
extent.  Paralysis  from  cold  may  occupy  both  lower  extremities  or  one- 
half  of  the  body.  Hoppe,  Romberg,  and  E.  H.  Weber  have  published 
examples  of  the  hemiplegic  type. 

With  regard  to  the  nature  of  the  motor  and  sensory  disorders  under 
discussion,  we  may  state,  in  accordance  with  the  experiments  and  patho- 
logical data  previously  referred  to,  that,  when  the  action  of  the  cold  is 
merely  superficial,  they  are  due  to  the  direct  action  of  the  chilling  of  the  vas- 
cular nerves  of  certain  regions.  When  the  action  of  the  cold  extends 
deeper,  the  phenomena  are  caused  by  a  reflex  irritation  of  the  vaso-motor 
and  spinal  systems,     in  substantiation  of  the  local  character  of  the  phe- 


DISEASES    OF   THE   NEKVOUS    SYSTEM.  165 

nomena,  "we  may  call  attention  to  the  paralysis  of  the  trigeminus  and  facial 
nerves,  to  the  facial  neuralgias  produced  by  the  action  of  cold,  the  local 
anaesthesia  obtained  by  Richardson's  method  (spray  of  ether  or  similar 
liquids),  and  the  anesthesia  of  the  hands,  observed  in  washerwomen.  We 
may,  finally,  refer  to  Nothnagel's  observations  (Arch.  f.  klin.  Med.,  II.  Bd., 
2.  H. )  of  local  anfemia  and  sensory  disturbances  (from  spasm  of  the  arterioles 
of  the  hands  and  forearms),  especially  in  women  engaged  in  washing  in 
cold  water.  I  also  observed  a  man,  a3t.  fifty  years,  of  a  neuropathic  consti- 
tution, who,  whenever  he  was  exposed  to  cold  during  the  autumn,  became 
affected  with  a  similar  vascular  spasm  in  both  hands,  especially  in  the  first 
three  fingers.  These  digits  became  numb,  pale,  and  flaccid,  but  were 
promptly  restored  to  the  normal  condition  under  the  influence  of  warmth. 

The  reflex  influence  of  cold  upon  the  vaso-motor  and  spinal  systems  is 
demonstrated  by  a  large  number  of  observations.  The  experiments  men- 
tioned above  with  regard  to  the  application  of  ice,  especially  to  the  ulnar 
nerve,  have  shown  that  the  increase  of  temperature  observed  in  the  course 
of  this  nerve  is  due  to  reflex  paralysis  of  the  sympathetic  nerves.  The 
elevation  of  temperature  in  the  limbs,  which  Chapman  noticed  after  the 
application  of  ice  to  the  vertebral  column;  the  cases  referred  to  above  of 
analgesia  or  even  of  motor  disturbances  in  the  limbs  after  extreme  cold; 
finally,  the  vascular  irritation  of  the  spinal  system  with  secondary  prolifer- 
ation of  connective  tissue  caused  by  chilling  of  the  feet  or  back, — are  fur- 
ther proofs  of  the  profound  reflex  action  of  cold  upon  the  sympathetic  and 
spinal  systems. 

The  diagnosis  of  these  paralyses  depends  upon  a  history  of  the  action 
of  cold  while  the  body  was  overheated,  and  followed  by  motor  and  sen- 
sory disturbances.  The  prognosis  is  usually  favorable  in  this  affection. 
In  slight  forms  and  in  young  subjects,  who  have  been  previously  healthy, 
the  disease  may  retrogress  spontaneously  and  may  disappear  in  one  or 
two  weeks.     In  more  severe  forms  it  may  persist  for  several  weeks. 

The  treatjnent  consists,  in  light  cases,  of  vapor-baths  followed  by  the 
douche.  When  the  disease  is  prolonged,  we  must  resort  to  the  use  of 
iodide  of  potassium  internally  and  externally,  and  then  to  electricity.  In 
paralysis  of  sensation,  the  employment  of  the  dry  electric  brush  is  useful; 
when  the  antesthesia  involves  the  deeper  parts,  the  skin  should  be  pre- 
viously moistened. 

We  may  diminish  the  force  of  the  electrical  current  as  the  sensibility 
gradually  returns.  In  paralysis  complicated  with  sensory  disorders,  good 
results  are  obtained  from  faradization  of  the  muscles,  and  especialh^  from 
galvanization  of  the  spinal  and  muscular  nerves.  Hydrotherapeutic 
measures  are  also  extremely  useful  (frictions,  moist  packs  continued  until 
the  v."armth  of  the  body  has  returned,  followed  by  half -baths  and  douches). 
Some  authors  also  recommend  sea-baths. 

Those  forms  which  are  usually  termed  rheumatic  paralyses  consist  of 
circumscribed  disorders  of  motion,  resulting  from  the  action  of  cold,  and 
appearing  in  the  forearm,  shoulder,  neck,  or  lower  limb.  The  paralysis 
occurs  most  frequently  in  the  forearm,  in  which  the  muscles  of  the  external 
region,  which  are  innervated  by  the  radial  and  are  more  exposed  to  cold 
than  the  others,  are  usually  affected.  By  mere  inspection  this  affection  is 
differentiated  with  difficulty  from  traumatic,  lead,  and  hysterical  paralyses. 
But,  in  wounds  of  the  radial  nerve,  all  the  muscles  which  it  innervates  are 
paralyzed  and  have  lost  their  electrical  contractility.  Lead  paralysis  af- 
fects, by  preference,  certain  muscles  in  a  definite  order,  and  almost  always 
appears  in  both  arms  at  the  same  time  (but  not  to  the  same  extent). 


166  CLIT^ICAL    TREATISE    OT^ 

In  hysterical  paralysis  the  electro-muscular  contractility  is  preserved,  but 
electro-muscular  and  electro-cutaneous  sensibility  are  diminished  or  abol- 
ished. 

In  recent  cases  of  rheumatic  paralysis  of  the  forearm,  the  electro- 
muscular  contractility  is  preserved,  and  the  electro-muscular  sensibility  is 
almost  always  increased.  In  old  cases,  whether  accompanied  by  muscu- 
lar atrophy  or  not,  a  moderate  diminution  of  electrical  contractility  and 
sensibility  becomes  noticeable.  In  these  cases  the  motor  power  becomes 
re-established  after  the  employment  of  faradization  of  the  muscles  or  of 
constant  labile  currents  (from  the  dorsal  spine  to  the  radial  nerve  or  to 
the  extensors).  The  use  of  vapor-baths  or  mineral  waters,  combined  with 
electricity,  also  furnishes  good  results. 

Muscular  rheumatism  is  not  infrequently  found  as  a  precursor  of  rheu- 
matic paralysis,  but  the  latter  only  appears  after  the  cessation  of  the 
pains  and  during  the  first  attempts  at  motion  performed  by  the  patient. 
As  Froriep  first  showed  (Ueber  Heilwirkungen  der  Elektricität,  1.  H., 
Die  rheumat.  Schwiele,  1843),  exudations  occur  in  rheumatic  affections 
which  he  described,  according  to  their  situation,  as  thickening  of  the 
connective  tissue,  skin,  muscles,  or  periosteum. 

True  rheumatic  myositis  originates  in  the  aponeurotic  cellular  tissue 
or  in  the  interstitial  connective  tissue  of  the  muscles.  The  great  vascular- 
ity of  the  muscles,  which  favors  the  development  of  inflammation,  also 
promotes  its  resolution,  though  it  may,  at  the  same  time,  lead  to  other 
sequences,  such  as  abscess,  induration,  calcareous  degeneration  of  the  exu- 
dation, and  fatty  degeneration.  The  period  of  irritative  symptoms  may 
be  followed  by  emaciation,  fall  of  temperature,  and  motor  disorders  (paral- 
ysis, contractures). 

In  many  instances,  muscular  rheumatism  appears  to  be  a  neuralgia  of  the  cutane- 
oas  and  muscular  branches  of  the  nerves,  which  have  been  subjected  to  the  action  of 
cold.  Beau  has  shown  (Arch.  Gen.,  Dec,  1862)  that  the  superficial  muscles  (occipito- 
frontalis,  deltoid,  trapezius,  sacrolumbalis)  are  most  sensitive  to  cold.  In  order  to 
preserve  the  affected  muscles  from  further  injury,  a  reflex  contraction  occurs  in  the 
adjacent  muscles.  Thus,  in  rheumatism  of  the  deltoid,  the  arm  is  pressed  against  the 
trunk  by  the  action  of  the  muscles  of  the  anterior  and  posterior  walls  of  the  axilla; 
in  rheumatism  of  the  trapezius,  the  diseased  muscle  is  relaxed  by  the  contraction  of 
the  sterno-cleido-mastoid  on  the  opposite  side ;  in  lumbago,  the  vertebral  column  is 
deflected  to  the  opposite  side  by  the  contraction  of  the  quadratus  lumborum  (perhaps 
also  of  the  intercostals).  The  treatment  must  be  regulated  in  accordance  with  the  pa- 
thogeny of  the  case. 

Although  muscular  rheumatism  is  a  mild  affection,  it  may  neverthe- 
less terminate  in  contracture  and  paralysis. 

Acute  muscular  rheumatism  often  terminates  spontaneously  after  rest 
and  simple  treatment.  Chronic  forms,  Avhich  are  complicated  with  atro- 
phy, paresis,  or  s^-mptoms  on  the  part  of  the  articulations,  require  local 
faradization  with  the  secondary  current,  or  local  applications  of  galvanism. 
Benefit  is  also  derived  from  daily  and  long-continued  employment  of 
moist  packs  applied  until  the  body  has  become  warm,  and  followed  by 
half-baths  and  douches.  Recent  rheumatic  contractures  are  often  rapidly 
relieved  by  the  passage  of  an  ascending  galvanic  current;  in  chronic  cases 
we  may  resort  to  faradization  of  the  antagonists,  or  to  local  galvanization 
with  currents  of  continually  increasing  intensity.  Rheumatic  paralysis 
yields  to  the  prolonged  application  of  the  induced  or  of  the  constant  labile 
current. 


DISEASES    OF   THE   NEKVOUS    SYSTEM.  167 

Those  conditions,  in  which  the  propagation  of  rheumatic  articular  in- 
flammations produces  myopathic  processes,  are  usually  included  under  the 
category  of  muscular  rheumatic  paralysis.  Thus,  rheumatic  arthritis  of 
the  shoulder  may  involve  the  deltoid  or  adjacent  muscles,  and  inflamma- 
tion of  the  cervical  vertebrae  may  lead  to  torticollis.  Periostitis  in  vari- 
ous regions  may  cause  paralysis  of  the  overl^dng  muscles. 

We  may  remark,  in  conclusion,  that  muscular  rheumatism  often  forms 
a  mask  under  w^hich  serious  affections  may  remain  concealed  for  a  long 
time. 

Progressive  muscular  atrophy,  vertebral  caries,  and  other  spinal  affec- 
tions are  often  mistaken,  in  the  beginning,  for  muscular  rheumatism,  al- 
though more  careful  examination  would  reveal  certain  motor  and  sensory 
disturbances  and  certain  electrical  reactions,  which  would  demonstrate 
the  danger  of  the  situation. 


168  CLINICAL   TREATISE    ON 


CHAPTER  XLII. 

TRAUMATIC   LESIONS    OF   THE   NERVES. 

In  his  experiments  upon  section  of  the  pneumogastric  nerve  in  dogs, 
Waller  found  (Mueller's  Archiv,  1853,  p.  392)  the  peripheral  portion  of 
the  nerve  disorganized  twelve  days  after  the  operation,  the  myeline  be- 
coming granular,  and  the  nerve-sheath  having  atrophied  in  great  part. 
At  the  end  of  four  weeks  the  nerve-fibres  were  found  to  be  regenerated. 
The  experiments  of  Schiff  (x\rch.  f.  gem.  Arbeit,  1853),  Valentin  (Zeit- 
schr,  f.  rat.  Med.,  XI.  Bd.,  18G1),  and  others  have  confirmed  the  occur- 
rence of  atrophy  and  disorganization  of  the  peripheral  ends  of  the  nerves 
and  of  the  final  absorption  of  the  medullary  substance  which  has  been 
transformed  into  fat.  These  changes  are  propagated  into  the  terminal 
peripheral  ramifications  of  the  nerves,  the  process  occupying  two  months 
in  young  animals  and  six  or  seven  months  in  older  ones. 

The  reunion  of  the  cut  ends  of  the  nerves  occurs,  in  favorable  cases, 
by  first  intention  (Bruch),  and  the  conductibility  and  normal  reactions  are 
often  re-established  at  the  end  of  a  month  (Lacrousille,  Union  Med.,  1864). 
When  a  considerable  portion  of  the  nerve  has  been  resected,  the  reunion 
occurs  by  means  of  a  bridge  which  projects  from  the  central  and  periph- 
eral ends  ;  according  to  Hjelt,  this  bridge  consists  of  an  enlargement 
formed  by  a  nuclear  proliferation  in  the  interstitial  connective  tissue. 
According  to  the  observations  of  Philipeaux  and  Vulpian  (Gaz.  Med.  de 
Paris,  37  et  seq.,  1860),  and  of  Schuh  (Med.  Wschr.,  1863),  regeneration 
and  re-establishment  of  conductibility  may  take  place,  even  if  the  excised 
portion  of  the  nerve  measures  thirty  millimetres  in  length. 

After  the  excision  of  considerable  portions  of  the  sciatic  or  crural 
nerves  in  animals,  Mantegazza  (Gaz.  Lombard,  1865-1867)  has  observed  a 
multiplication  of  the  muscular  nuclei,  cloudiness,  partial  fatty  degenera- 
tion, or  simple  atrophy  of  the  primitive  fibres;  finally,  atrophy«of  the  mus- 
cles with  hyperplasia  of  the  interstitial  connective  tissue. 

In  addition,  periostitis,  abscesses,  osseous  affections  with  caries  and 
necrosis,  osteophytes,  and  hypertrophy  of  the  spongy  substance  of  the 
bones,  may  develop  in  the  paralyzed  limbs. 

Erb  (Arch.  f.  klin.  Med.,  V.  Bd.,  1868),  in  the  course  of  his  experi- 
ments on  peripheral  paralysis,  observed  the  persistence  of  the  axis  cylin- 
ders, in  addition  to  the  previously  mentioned  degeneration  of  the  myeline; 
during  the  period  of  recovery,  a  regeneration  of  the  myeline  occurred  in  a 
centrifugal  direction ;  the  neurilemma  was  the  seat  of  an  abundant  cellu- 
lar infiltration,  and  its  connective  tissue  was  considerably  thickened. 

The  changes  observed  in  the  muscles  consisted  of  marked  atrophy  of 
the  fibres  (reduced  in  four  or  five  weeks  to  less  than  half  their  normal  di- 
mensions), cloudiness,  though  not  complete  disappearance  of  the  trans- 
verse strias,  and  considerable  multiplication  of  the  muscular  nuclei;  the 
final  change  in  the  contractile  substance  consisted  of  waxy  degeneration 
and  rupture  of  the  fibres.     An  early  and  considerable  accumulation  of 


» 


DISEASES    OF   THE   NEEVOUS    SYSTEM.  169 

round  cells  is  noticeable  in  the  interstitial  connective  tissue,  and  is  fol- 
lowed by  very  marked  increase  of  this  tissue. 

In  the  reproduction  of  divided  nerves,  the  external  sheath  of  the 
nerve-tubes  is  formed,  according  to  Robin  (Journ.  de  I'Anat.  et  de  la  Phy- 
siol., VIII.,  1868),  from  the  adjacent  nuclei;  a  liquid,  refractile  myeline 
then  appears  in  the  centre  of  the  new-formed  fibres,  and,  at  the  end  of  six 
to  nine  weeks,  it  becomes  more  abundant  in  certain  portions  of  the 
sheath,  imparting  to  the  latter  a  varicose  appearance.  The  axis  cylinder 
only  becomes  visible  after  the  lapse  of  three  or  four  months. 

According  to  the  investigations  of  Hertz  (Virch.  Arch.,  46.  Bd.,  3.  H., 
1869),  the  intermediate  substance  takes  an  active  part  in  the  regenerative 
process,  by  a  proliferation  of  cells  (at  the  expense  of  the  white  blood 
globules)  and  their  transformation  into  nerve-fibres.  The  cells  of  the 
neurilemma  also  play  an  important  part,  by  the  transformation  of  their 
nuclei  into  ribbon-shaped  masses  which  become  united  to  the  old  and 
new  nerve-fibres.  We  may  finally  refer  to  the  observations  of  Bizzozero 
and  Golgi  (Wien.  Med.  Jahrb.,  1.  H.,  1873).  After  excision  of  the  sciatic 
and  crural  nerves  in  rabbits,  these  authors  have  observed  enlargement  of 
the  joints  and  ulcers  upon  the  extremities;  in  the  deep  muscles,  which 
were  pale  and  waxy,  the  fibrillary  tissue  was  replaced  by  a  considerable 
development  of  fatty  cells. 

Vulpian  (Arch,  de  Physiol.,  1869)  has  examined  the  muscles  in  a  case 
of  resection  of  the  hip-joint  (six  months  previously,  in  removing  a  tumor, 
a  portion  of  the  sciatic  nerve  had  been  excised).  He  found  the  histologi- 
cal changes  referred  to  by  Mantegazza  and  Erb. 

We  shall  now  pass  in  review  the  anatomical  and  experimental  inves- 
tigations concerning  the  clinical  syniptoins  of  traumatic  lesions  of  the 
nerves.  The  nerve-trunks  are  exposed  to  various  kinds  of  traumata, 
such  as  section,  crushing,  tearing,  violent  concussion,  luxation,  persistent 
compression,  cauterization,  and  suppuration.  The  inconsiderable  lesion 
of  the  sensory  fibres  in  wounded  nerve-trunks  has  been  confirmed  by  re- 
cent observations.  According  to  Schiff's  experiments  upon  the  cord,  this 
circumstance  must  be  explained  by  the  greater  vulnerability  of  the  motor 
compared  to  that  of  the  sensory  fibres. 

Among  the  sensory  disorders,  traumatic  hyperfesthesia  must  be  men- 
tioned in  the  first  rank.  It  may  be  situated  in  the  skin  or  muscles.  An 
extremely  remarkable  but  very  rare  phenomenon  is  the  general  hyperses- 
thesia,  which  has  been  observed  by  American  military  surgeons,  in  two 
cases  by  Smoler,  and  in  one  by  myself.  The  hypergesthesia  may,  after 
cicatrization  of  the  wound,  extend  to  the  trunk  and  to  the  entire  body, 
and  may  attain  such  an  insupportable  intensity  that  the  patient  cannot 
endure  the  lightest  contact  or  the  slightest  current  of  air,  and  cannot 
obtain  any  repose  or  execute  any  movements,  except  by  covering  the 
limbs  with  frequently  renewed  compresses  of  cold  water.  The  irritation 
caused  by  the  wound  appears  to  extend  to  the  posterior  roots  and  gray 
columns  of  the  cord,  and  to  produce  an  exaggerated  excitability.  The 
treatment  consists  of  cold  compresses,  prolonged  baths,  and  subcutaneous 
injections  of  morphine. 

The  anaesthesia  of  the  skin  and  muscles,  which  often  accompanies 
motor  paralysis  of  the  mixed  nerves,  may  be  complete  or  incomplete, 
and,  in  the  latter  event,  it  is  evidence  of  the  complete  isolation  of  the 
nerve  from  the  spinal  centres.  If  it  accompanies  motor  disorders  which 
are  secondary  to  acute  pains  along  the  distribution  of  the  nerves,  we  are 
justified   in  diagnosing   a  traumatic   neuritis.     Before  sensibility  is  re- 


170  CLINICAL   TREATISE    ON 

stored,  the  anagsthesia  becomes  transformed  into  hyperaesthesia.  The 
treatment  consists  in  the  employment  of  the  faradic  brush  (with  the  sec- 
ondary current),  or  in  the  passage  of  strong  labile  currents  through  the 
dorsal  spine  and  the  peripheral  nerves. 

Traumatic  neuralgias  usually  occupy  a  more  or  less  limited  portion  of 
the  nerve-trunks  and  are  accompanied  by  certain  painful  points.  The 
neuralgia  following  venesection  is  due  to  a  wound  of  the  musculo-cuta- 
neous  nerve,  and  not  of  the  median  nerve,  as  was  formerly  believed.  The 
pains  often  assume  a  paroxysmal  character,  attended  with  more  or  less 
complete  remissions.  The  treatment  consists,  in  slight  cases,  of  the  em- 
ployment of  cold  compresses,  of  moist  packs  continued  until  the  return 
of  warmth  to  the  body,  followed  by  cool  half-baths,  and  of  blisters  or 
subcutaneous  injections  of  morphine.  In  severe  or  chronic  cases  we  are 
sometimes  compelled  to  resort  to  the  actual  or  potential  cautery,  to  sub- 
cutaneous section  of  the  nerves  (neurotomy),  or  even  to  excision  (neu- 
rectomy). 

In  a  case  reported  in  the  work  on  "Gunshot  Wounds  and  other  Injuries  of  Nerves  : 
Weir  Mitchell,  Morehouse,  and  Keen,"  a  portion  of  the  median  nerve,  two  centimetres 
in  length,  was  excised  with  temporary  success. 

Contracture  and  paralysis  constitute  the  most  rebellious  and  distress- 
ing motor  disorders  of  traumatic  origin.  In  many  cases  the  contracture 
is  due  to  a  tonic  spasm  of  the  antagonists,  caused  by  paralysis  of  certain 
muscles.  The  stiffness  of  the  joints,  which  occurs  after  fractures  or  other 
accidents,  is  due  in  great  part  to  the  forced  immobility  of  the  limbs  in 
immovable  apparatus.  In  such  cases  we  may  often  prevent  bad  after- 
effects by  passive  movements,  performed  frequently  and  carefully.  In 
other  cases  the  contractures  followinor  traumatism  are  of  reflex  orisrin, 
such  as  occurs  when  acute  hyperaesthesia  is  present  in  wounds  of  very 
sensitive  organs,  like  the  joints,  and  which  may  cause,  by  reflex  means,  a 
spasmodic  contraction  of  those  parts  which  tend  to  relieve  the  pain. 
In  these  cases  the  reflex  phenomena  are  sometimes  due  to  irritation  of 
certain  portions  of  distant  nerves. 

Treatment. — When  the  spasmodic  contraction  of  the  muscles  has  only 
lasted  a  short  time,  when  there  is  no  atrophy,  and  when  the  spasm  varies 
from  day  to  day,  relaxation  of  the  muscles  may  be  produced,  according 
to  American  physicians,  by  injections  of  atropine  or  by  etherization.  In 
contractures  of  reflex  origin,  benefit  is  derived  from  the  application  of 
galvanism  to  the  wounded  nerves,  and  from  faradization  of  the  paralyzed 
muscles. 

Our  clinical  knowledge  of  traumatic  paralysis  dates  back  to  the  ex- 
cellent investigations  made  by  Duchenne.  The  discoveries  made  by  ex- 
perimental pathologists  agree,  in  great  part,  with  the  results  of  clinical 
observation. 

Among  the  experimental  investigations  undertaken  in  recent  times, 
we  must  especially  refer  to  those  of  Erb  (Deutsch.  Arch.  f.  klin.  Med.,  IV. 
und  V.  Bd.,  1868),  and  Ziemssen  and  Weiss  (eod.  loc,  IV.  Bd.,  p.  599- 
594).  Erb  has  shown  that  the  nerves  and  muscles  acquire  entirely  different 
electrical  reactions.  In  the  nerves  the  irritability  to  both  currents  di- 
minishes gradually  from  the  beginning  of  the  paralysis  and  disappears  com- 
pletely at  the  end  of  one  or  two  weeks.  After  the  lapse  of  a  variable 
time,  it  becomes  very  slpwly  re-established  (proceeding  from  the  central 
end),  the  galvanic  excitability  being  usually  restored  more  rapidly  than 


DISEASES    OF   THE    TSTEEVOUS    SYSTEM.  171 

the  faradic.  As  a  rule,  the  electrical  excitability  is  not  recovered  until 
long  after  the  return  of  voluntary  motion.  The  peripheral  end  of  the 
nerve  may  therefore  be  permeable  to  voluntary  impulse  before  it  has  re- 
covered its  receptivity  for  external  stimuli. 

In  the  muscles  the  irritability  to  both  currents  also  gradually  diminibhes 
during  the  first  few  weeks.  The  faradic  excitability  then  progressively 
diminishes,  but  the  galvanic  irritability  becomes  markedly  increased  from 
the  close  of  the  second  week  (it  is  relatively  stronger  at  the  closure  of  the 
anode  than  of  the  cathode).  Finally,  after  the  lapse  of  a  variable  period 
the  galvanic  irritability  again  sinks  below  the  normal,  while  the  faradic 
excitability  is  slowly  restored.  Simultaneously  and  almost  parallel  with 
the  increase  of  galvanic  excitability,  the  muscles  also  present  exaggerated 
mechanical  excitability. 

According  to  Erb,  the  anatomical  processes  which  are  present  in  these 
modifications  of  electrical  excitability,  present  the  greatest  analogies  with 
inflammation,  especially  with  those  chronic  forms  which,  in  certain  organs, 
terminate  in  cirrhosis.  The  origin  of  these  lesions  must  be  attributed  to 
the  vaso-motor  and  trophic  fibres  passing  through  the  nerve-trunks  which 
have  been  affected  by  the  injury.  Erb  also  believes  that  the  conductibility 
and  mechanical  excitability  occur  through  the  regenerated  axis  cylinders, 
and  that  the  electrical  excitability  is  due  to  the  presence  of  the  myeline 
sheath.  This  view  is  opposed  to  Eulenburg's  theory  that  the  excitability 
of  the  nerves  is  due  to  the  existence  of  a  specific  force. 

Ziemssen  and  Weiss  have  produced  paralysis  of  varying  intensity  and  duration  by 
applying  silk  ligatures  with  variable  force  to  the  nerves.  The  slight  paralyses  were 
characterized  by  abolition  of  motor  power,  loss  of  farado-miiscular  contractility,  in- 
crease of  galvano -muscular  excitability,  and  diminution  of  the  electrical  excitability 
of  the  nerves.  In  the  paralyses  of  moderate  intensity  there  is  loss  of  motor  power, 
and,  at  the  end  of  one  or  two  days,  the  nerves  are  entirely  in  excitable  to  both  currents  ; 
the  galvano-muscular  excitability  increases,  and  the  faradomuscular  excitability 
diminishes  until  it  is  completely  abolished.  The  duration  of  these  paralyses  varies 
from  three  to  six  months,  after  which  the  normal  condition  is  slowly  re-established. 
The  most  severe  paralysis  (from  excision  of  the  nerve)  presents  almost  the  same  modi- 
fications as  the  moderate  forms,  with  the  exception  that  the  galvano-muscular  ex- 
citability does  not  increase,  but  diminishes  pari  pasni  with  the  faradic  excitability 
until  it  is  entirely  suppressed  ;  it  becomes  re-established  after  six  to  eight  months  at 
the  same  time  with  the  conductibility.  Atrophy  of  the  muscles  with  induration  and 
contracture  is  always  noticeable,  but  this  condition  disappears  after  the  retiurn  of  con- 
ductibility. 

The  results  obtained  in  animals  are  also  applicable  in  great  part  to  the 
phenomena  observed  in  man.  The  excitability  of  the  nerves  to  the  in- 
duced and  constant  currents  undergoes,  from  the  onset  of  the  paralysis,  a 
diminution  which  extends  towards  the  periphery.  At  the  end  of  the 
second  or  third  week  the  nerves  have  manifestly  lost  their  excitability  to 
both  currents.  The  electrical  irritability  of  the  nerves  returns  when  the 
motor  power  is  restored;  contractions  upon  closure  at  the  cathode  are 
temporarily  observed  at  an  early  period.  Experience  has  confirmed  the 
appearance  of  all  these  characteristic  symptoms  in  man.  The  electrical 
irritability  of  the  nerves  is  independent  of  their  excitability  to  the  stimu- 
lus of  the  will. 

In  the  muscles  the  electrical  excitability  in  general  is  lost  in  the  be- 
ginning, and  this  is  followed  by  increase  of  galvanic  excitability  with  per- 
sistent abolition  of  faradic  reaction  (as  is  shown  by  the  cases  of  traumatic 
paralysis  of  the  nerves  of  the  brachial  plexus,  reported  by  Ziemssen, 
Gruenwald,  Erb,  and  Eulenburg,  or  by  Brenner's  cases  of  traumatic  neu- 


172  CLINICAL   TEEATISE    OK" 

ritis).  This  peculiar  fact  is  due,  according  to  Neumann's  investigations,  to 
the  following  circumstances  :  the  muscular  tissue,  destitute  of  nerves,  is 
insensible  to  the  momentary  action  of  the  induced  current,  or  to  the  gal- 
vanic current  when  it  is  also  applied  interruptedly;  it  will  respond,  how- 
ever, to  a  current  whose  duration  is  not  merely  instantaneous,  although 
these  contractions  are  always  very  slow  and  tardy.  An  increase  of  the 
mechanical  irritability  of  the  muscles  (Erb)  is  almost  always  noted  in 
addition  to  the  increase  in  the  galvanic  excitability.  At  a  later  period 
the  galvanic  excitability  diminishes,  and  the  direct  faradic  irritability 
gradually  returns.  The  modifications  of  the  muscular  irritability  are  very 
different  from  the  phenomena  presented  by  the  nerves.  In  certain  in- 
stances, in  which  faradization  through  the  skin  produced  no  contraction, 
I  have  seen  the  muscles  react  to  electro-puncture.  This  is  probably  due 
to  a  quantitative  difference  in  the  current,  which  traverses  the  muscles 
through  a  very  circumscribed  space. 

According  to  Duchenne,  the  electro-muscular  and  electro-cutaneous 
sensibility  are  less  altered,  as  a  rule,  in  traumatic  paralysis  than  the 
contractility.  The  former  is  only  abolished  in  those  cases  in  which  the 
nerve  is  completely  separated  from  the  spinal  centre.  The  muscles  whose 
electrical  contractility  and  sensibility  are  only  slightly  affected,  recover 
rapidly  under  the  influence  of  faradization,  while  those  which  are  deprived 
of  faradic  contractility  and  sensibility  soon  atrophy.  Nevertheless,  a 
muscle  may  preserve  the  power  of  voluntary  motion,  although  the  electri- 
cal contractility  has  been,  in  great  part,  lost.  Sometimes,  on  the  other 
hand,  a  muscle  is  paralyzed,  although  its  faradic  irritability  persists. 

The  paralysis  caused  by  crushing  the  nerve  plexuses  sometimes  pre- 
sents the  characteristics  of  progressive  muscular  atrophy,  as  I  had  occasion 
to  notice  in  a  woodsman,  who  received  a  blow  upon  the  left  shoulder  from 
a  falling  oak  (representing,  according  to  his  statement,  four  cords  of  wood). 
He  immediately  lost  consciousness,  and  the  upper  limb  began  to  swell;  at 
the  end  of  six  months  the  arm  and  forearm  had  atrophied,  the  movements 
of  the  shoulder  and  neck  were  abolished,  and  electrical  contractility  was 
lost  in  the  majority  of  the  muscles  of  the  arm  (except  the  common  exten- 
sor of  the  fingers,  the  long  abductor  of  the  thumb,  and  the  muscles  of  the 
wrist,  which  still  presented  a  very  feeble  reaction).  In  a  second  case  (oc- 
curring during  the  Bohemian  war),  a  ball  had  penetrated  above  the  axilla, 
and  had  produced  a  partial  lesion  of  the  brachial  plexus  (paralysis  and 
loss  of  electrical  contractility  in  the  majority  of  the  extensor  muscles). 
The  latter  patient  was  considerably,  and  the  former  very  little,  improved 
by  galvanization. 

During  the  battle  of  Sadowa,  a  private  received  a  gun-shot  wound  in  the  lower  half 
of  the  popliteal  space  upon  the  left  side  ;  five  dnys  later  he  was  examined  in  the  hos- 
pital of  Voeslau  (near  Vienna).  Voluntary  motion,  the  galvanic  and  faradic  excitabil- 
ity in  the  peroneal  and  tibial  nerves,  and  the  electrical  contractility  of  the  muscles  of 
the  anterior  and  posterior  regions  of  tlie  leg  were  abolished.  The  toes  and  sole  of 
the  foot  were  anaesthetic  in  great  part,  certain  muscles  reacted  slowly  to  a  strong  con- 
tinuous current ;  the  sciatic  nerve  had  been  implicated  by  the  bullet  at  its  point  of 
division.  After  the  employment  of  warm  baths  and  intermittent  faradization  for  a 
period  of  twenty  days,  sensibility  first  returned,  and  then,  little  by  little,  the  patient 
was  able  to  perform  movements  while  lying  in  bed.  At  the  end  of  the  sixth  week 
the  patient  could  walk,  but  he  was  soon  transferred,  and  I  was  unable  to  detect  any 
considerable  improvement  in  the  excitability  of  the  nerves  to  both  currents,  or  in  the 
farado- muscular  contractility,  at  the  time  of  his  departure. 

Recurrent  sensibility  (preservation  of  peripheral  sensibility  after  com- 
plete section  of  the  nerves)  has  been  observed  by  Laugier,  Nelaton,  Du- 


DISEASES    OF   THE    NEEVOUS    SYSTEM.  173 

chenne,  Revillout,  and  Riebet,  and  most  frequently  in  the  median  nerve. 
This  symptom  is  explained  by  the  hypothesis  that  anastomoses  exist  be- 
tween the  nerves  of  the  arm,  which,  after  section  of  one  of  these  nerves, 
permits  centripetal  conduction  in  the  others.  Laveran  (These  de  Strasb., 
1SG8),  and  Arloing  and  Tripier  (Arch,  de  Phys.,  II.,  1869)  have  shown 
that  the  peripheral  nerve-trunks  which  remain  sensitive  contain,  at  the 
end  of  a  certain  length  of  time,  some  nerve-fibres  which  have  escaped  de- 
generation. We  may  also  admit  that  recurrent  fibres  of  the  ulnar  and 
radial,  or  anastomoses  between  the  median  and  ulnar  (Gruber)  give  rise 
to  the  sensibility  in  the  fibres  of  the  median  situated  below  the  point  of 
section.  According  to  Letievant  (Traite  des  sect.  Nerv.,  1873),  the  sup- 
plementary sensibility  may  be  indirectly  established  by  irritation  of  the 
cutaneous  sensory  papillte  in  the  immediate  neighborhood.  In  *'  supple- 
mentary "  motor  power  (preservation  of  the  motor  functions  without  re- 
generation of  the  nerves)  the  adjacent  muscles  which  are  supplied  by 
other  nerves  assume  the  functions  of  the  paralyzed  muscles. 

The  vaso-motor  disturbances  which  occur  in  the  course  of  traumatic 
nerve  lesions  are  explained  by  the  abundance  of  vaso-motor  fibres  con- 
tained in  the  large  nerve-trunks  of  the  limbs.  According  to  the  experi- 
ments of  CI.  Bernard  and  Schiff,  section  of  the  brachial  plexus  or  sciatic 
nerve  is  followed  by  redness  of  the  limb  and  considerable  elevation  of 
temperature.  In  section  of  the  large  nerve-trunks,  in  man,  an  acute  stag-e 
of  vaso-motor  paralysis  is  observed,  that  is  to  say,  an  elevation  of  temper- 
ature from  the  sudden  increase  in  the  afflux  of  arterial  blood.  This  is 
followed  by  a  chronic  stage,  in  which  the  retardation  of  the  current  of 
blood  and  the  passive  hyperaemia  produce  lowering  of  the  temperature. 
In  addition  to  these  phenomena,  which  authors  have  not  differentiated 
sufficiently,  there  are  various  kinds  of  trophic  disorders.  Thus  in  two 
cases,  reported  by  Hutchinson  (Med.  Times  and  Gazette,  659,  1863),  sec- 
tion of  the  nerves  of  the  arm  was  accompanied  by  lividity  of  the  skin, 
incurvation  of  the  nails,  and  lesions  of  the  extremities  of  the  fingers  (pa- 
ronychia). American  physicians,  and  Rouget,  Fisher,  etc.,  have  also  ob- 
served changes  in  the  skin  (glossy  skin,  eczematous  eruptions,  disorders 
of  secretion),  and  arthropathies.  Gangrenous  ulcerations  of  the  super- 
ficial parts,  from  wounds  of  the  nerve-trunks,  have  been  observed  experi- 
mentally and  clinically.  In  a  case  of  ulnar  paralysis,  which  I  shall  re- 
port at  a  later  period,  the  hairs  grew  very  abundantly  upon  the  back  of 
the  hand  on  the  wounded  side.  Schiff  and  Rettberg  have  noticed  the 
same  fact  in  animals  after  section  of  the  nerves  of  the  concha  of  the  ear 
and  of  the  limbs. 

According  to  Brown-Sequard  and  Charcot,  these  trophic  disorders  are 
only  produced  in  man  when  the  nerves  are  irritated,  while  in  animals  the 
inflammatory  symptoms  do  not  appear  after  neurotomy,  and  are  only 
manifested  after  contusion  of  the  nerves.  The  muscular  atrophy,  which 
is  so  pronounced  and  rapid  in  traumatic  paralysis,  is  poorly  explained  by 
the  simple  abolition  of  the  muscular  functions,  since  in  cerebral  paralysis, 
even  when  complete  and  persisting  for  several  years,  the  nutrition  and  re- 
action of  the  muscles  are  not  essentially  changed.  The  disorders  in  the 
nutrition  of  the  muscles,  like  those  in  other  parts,  must  be  regarded  as 
traumatic  disturbances  of  trophic  innervation.  We  are  led  to  adopt  this 
view  so  much  the  more  readily  because  the  anatomical  and  clinical  facts, 
previously  discussed  in  a  large  number  of  diseases,  have  led  us  to  admit 
the  existence  of  trophic  centres  in  the  cells  of  the  anterior  gray  horns, 
which  are  connected  with  the  peripheral  parts  by  means  of  trophic  fibres. 


174  CLINICAL    TREATISE    ON 

la  a  case  whicli  occurred  during  tlie  late  war  (communicated  by  Dr.  Herzog),  pa- 
ralysis of  the  peroneal  nerve  occurred,  with  elevation  of  temperature  at  the  onset  in 
the  corresponding  parts  of  the  leg.  After  the  wound  had  healed  by  second  intention, 
a  considerable  reduction  of  temperature  occurred,  attended  with  cyanosis  and  super- 
ficial ulceration  of  the  soft  parts  of  the  ungual  phalanges. 

In  a  paralysis  of  the  right  ulnar  nerve  (from  a  sabre  wound),  I  found,  at  the  end 
of  the  fourth  month,  motor  and  sensory  paralysis  of  the  corresponding  fingers,  a 
depression  in  the  fourth  intercostal  space,  atrophy  of  the  hypothenar  eminence, 
bluish  coloration  of  the  little  finger,  and  a  strong  growth  of  hair  upon  the  correspond- 
ing dorsal  aspect  of  the  right  hand.  According  to  the  statement  of  the  patient,  this 
had  not  been  present  before  the  receipt  of  the  injury;  it  contrasted  very  markedly 
with  the  smooth  condition  of  the  left  hand.  Thermometric  measurements  were 
made  (in  a  room  with  a  temperature  of  16°  C),  and  showed,  upon  the  right  side,  be- 
tween the  little  and  ring  fingers,  27.3°,  upon  the  left  side  34.8°  C;  between  the 
index  and  middle  fingers,  on  the  right  side,  34.2^  C,  on  the  left  34.5°;  upon  the  dor- 
sal surface  of  the  little  finger,  on  the  right  side,  26  2°,  on  the  left  32.2°  C.  After 
faradic  or  galvanic  stimulation  of  the  nerve  or  muscles,  the  temperature  rose,  upon 
the  right  side,  between  the  little  and  ring  fingers,  to  30.6°  C.  The  paralyzed  muscles 
did  not  respond  to  the  induced  current ;  upon  galvanization  (thirty  small  Siemens' 
elements)  slow  contractions  were  obtained  in  the  hyjiothenar  eminence  and  fourth 
interosseous  space  ;  motor  and  sen.sory  reactions  were  evinced  upon  passing  galvanic 
currents  from  the  dorsal  spine  to  the  nerves,  or  faradic  currents  from  the  nerves  to 
the  muscles.  Under  the  influence  of  a  mixed  treatment,  continued  for  six  weeks, 
some  of  the  muscles  of  the  little  finger  became  sensitive  to  the  faradic  current,  the 
functions  of  the  right  hand  were  partially  restored,  and  improvement  with  regard  to 
temperature  also  occurred. 

Different  nerves  are  iinequally  exposed,  on  account  of  their  position, 
to  traumatic  lesions.  Thus,  according  to  Londe's  statistics,  among  fifty- 
seven  cases  the  median  nerve  was  implicated  six  times,  the  radial  five 
times,  the  internal  saphenous  three  times,  the  infraorbital  three  times,  the 
patheticus,  facial,  ulnar,  sciatic,  and  digital  nerves  each  twice,  and  ten 
other  nerves  each  once. 

We  may  also  refer  to  reflex  traumatic  paralysis,  which  has  been 
more  carefully  studied  in  recent  times,  especially  by  American  physicians 
(loc.  cit.).  After  a  gun-shot  wound  or  contusion,  paralysis,  either  of 
motion  or  sensation  or  of  both  combined,  develops  in  a  limb  which  is  re- 
moved from  the  seat  of  injury,  although  those  parts  of  the  body  which 
have  been  directly  affected,  remain  free  from  any  morbid  phenomena.  As 
we  have  previously  discussed  the  nature  of  reflex  paralysis  in  general 
(page  152),  we  shall  merely  remark,  with  regard  to  the  traumatic  forms, 
that  the  irritation  created  by  the  wound  may  give  rise  to  changes  through- 
out a  large  part  of  the  nervous  centres,  if  the  latter  are  in  a  condition  of 
abnormal  irritability,  such  as  occurs,  among  general  neuroses,  in  tetanus. 
If,  on  the  other  hand,  the  irritation  is  conveyed  to  more  circumscribed 
portions  of  the  nerve-centres,  it  will  give  rise  to  isolated  paralyses.  In 
the  latter  event,  certain  nerves  usually  present  an  increased  sensibility  to 
pressure  and  an  exaggeration  of  their  reflex  and  galvanic  excitability. 

The  prognosis,  in  traumatic  paralysis,  varies  according  to  the  intensity 
of  the  nerve  lesions.  If  the  nerve  is  completely  divided  and  nutrition 
markedly  affected,  the  chronicity  of  the  affection  will  only  increase  the 
dangers.  The  less  the  electro-muscular  contractility  and  sensibility  have 
been  affected,  the  sooner  will  electricity  produce  good  results,  according 
to  Duchenne.  The  prognosis  is  favorable  if  contractility  is  abolished 
but  sensation  has  suffered  little  or  not  at  all.  When  all  phenomena  of 
contraction  and  sensation  are  abolished,  the  paralyzed  muscles  will  atrophy, 
even  though  they  respond  to  the  faradic  current.  A  serious  grade  of 
paralysis   is   indicated  by  loss  of  farado-muscular  and  preservation   of 


DISEASES    OF   THE    NERVOUS    SYSTEM.  175 

galvano-muscular  contractility.  Even  in  severe  lesions  of  the  nerves, 
persistent  treatment  may  preserve,  at  least  in  part,  the  functions  of  the 
limbs.  According  to  Duchenne,  the  return  of  sensibility  and  the  trans- 
formation of  anaesthesia  into  hyperjesthesia  constitute  favorable  signs 
which  are  indicative  of  beginning  recovery;  the  temperature,  muscular 
tonicity,  and  power  of  voluntary  motion  will  then  gradually  return  to  the 
normal.  According  to  the  gravity  of  the  case,  two,  four,  six  months,  and 
perhaps  a  longer  interval,  will  elapse  before  even  moderately  satisfactory 
results  are  obtained.  From  Baerwinkel's  recent  observations  (Arch.  d. 
Heilk.,  XII.  Bd.,  1871),  it  appears  that  if  compression  of  mixed  nerve- 
trunks,  below  the  point  of  injury,  produces  peripheral  sensations,  we  may 
conclude  that  the  sensory  nerves  have  preserved  their  connections  with  the 
centres,  and  this  will  also  apply  in  part  to  the  motor  fibres.  In  the  ab- 
sence of  these  effects  of  compression,  we  are  not  justified  in  admitting  a 
solution  of  continuity  if  we  can,  at  the  same  time,  discover  symptoms  of 
irritation  in  the  nerves. 

With  regard  to  treatment^  Duchenne  favors  the  faradization  of  the 
paralyzed  muscles.  This  is  at  first  employed  with  strong,  rapidly  inter- 
rupted currents,  and  then  with  weaker  currents  (daily  sittings  of  ten  to 
fifteen  minutes).  Duchenne  states  that  faradic  treatment  is  more  service- 
able and  more  indicated  in  old  than  in  recent  cases.  I  believe  that, 
without  interfering  with  the  process  of  reproduction,  we  may  resort  to 
electricity  at  an  early  period  in  order  to  stimulate  the  muscular  nutrition 
and  activity  and  to  prevent  tissue  changes.  It  has  not  been  demon- 
strated that  the  constant  current  has  a  more  positive  action  upon  the 
course  of  severe  paralyses.  The  treatment  which  has  afforded  the  best 
results  in  my  hands  has  been  the  employment,  upon  alternate  days,  of 
galvanization  of  the  nerves  by  means  of  descending  currents  (from  the 
dorsal  spine  and  plexuses),  and  the  application  of  the  induced  current  to 
the  muscles.  Further  surgical  investigations  must  decide  upon  the  value 
of  sutures  of  the  nerves. 


176  CLINICAL   TEEATISE    ON 


CHAPTER  XLIII. 
Diseases  of  the  Cranial  and  Spinal  Neeves. 


DISEASES  OF  THE  PEEIPHEBAL  NEEVES  IN  GENERAL. 

In  the  treatment  of  diseases  of  the  peripheral  nerves  (nerve-roots, 
nerve-trunks,  and  peripheral  ramifications),  we  are  frequently  arrested  by 
the  insurmountable  difficulty  of  accurately  determining  the  etiological  con- 
ditions of  these  affections,  which  are  still  involved  in  so  much  obscurity. 
We  shall  restrict  ourselves  to  the  symptomatic  part  of  the  question, 
and,  in  order  to  meet  the  requirements  of  practice,  we  shall  describe  these 
various  nervous  diseases  according  to  their  clinical  signs,  referring  also 
to  what  is  known  concerning  their  anatomical  changes,  and  aiding  diag- 
nosis and  treatment  by  a  minute  analysis  of  the  symptoms.  Before  en- 
tering upon  the  special  diseases  of  the  cranial  and  spinal  nerves,  we  will 
take  a  general  survey  of  the  most  important  morbid  forms,  viz. :  atrophy, 
hypertrophy,  and  neuroma,  neuritis  and  neuralgia. 


a.  Atrophy  of  the  Iferves. 

Atrophy  of  the  nerves  is  a  process  which  accompanies  the  most  varied 
central  and  peripheral  affections.  In  the  first  chapters  of  this  work  the 
atrophy  occurring  in  cerebral  diseases  has  been  discussed  in  detail.  We 
refer  to  the  corresponding  chapters  for  information  concerning  the 
atrophy  of  the  roots  of  the  cranial  nerves  in  bulbar  paralysis,  that  which 
involves  entire  nerve-trunks  in  spinal  affections,  and  the  atrophy  of  the 
anterior  columns  and  roots  in  progressive  muscular  atrophy.  The  atrophy 
of  the  nerves  of  the  organs  of  special  sense  has  been  referred  to  under  the 
head  of  cerebral  tumors. 

In  the  central  parts,  as  well  as  in  the  peripheral  nerves,  the  atrophy 
may  be  primary,  and  due  to  spontaneous  amyloid  degeneration;  or  it 
may  be  secondary ,  in  which  event  its  causes  may  be  traced  more  accu- 
rately. The  atrophy  of  the  nerves  is  sometimes  caused  by  an  obstruc- 
tion to  the  flow  of  blood.  Solutions  of  continuity  in  the  nerves,  their 
separation  from  the  central  nutritive  foci,  and  the  obstacles  to  the  repro- 
duction of  the  cut  ends,  constitute  some  of  the  causes  which  lead  to 
atrophy.  In  many  cases,  inflammation,  by  causing  a  persistent  exuda- 
tion or  connective-tissue  proliferation,  may  cause  atrophy  of  the  nerves, 
which  are  almost  always  adherent  to  the  surrounding  parts.  Finally, 
long-continued  compression  is  often  a  cause  of  this  process.  The  com- 
pression may  follow  an  injury;  or  tumors,  caries,  periostitis  of  bony 
canals  through  which  the  nerves  pass,  exostoses,  aneurisms,  and  glandu- 
lar degenerations  may  give  rise  to  the  atrophy. 


DISEASES    OF   THE   NERVOUS    STSTEJM.  177 

The  affected  nerve  is  usually  thin,  and  presents  a  grayish  or  yellowish 
appearance.  The  microscope  revels  a  considerable  number  of  large 
nerve-fibres;  in  others,  the  myeline  and,  afterwards,  the  axis-cylinder  be- 
come transformed  into  fat,  and  the  neurilemma  is  sclerosed;  according  to 
Bibra,  the  atrophied  nerves  contain  a  much  smaller  proportion  of  water 
than  normally. 

When  the  atrophy  is  due  to  inflammation  or  compression,  it  is  often 
preceded  by  symptoms  of  irritation,  such  as  parjesthesia,  neuralgia,  iso- 
lated contractions  ;  when  the  conductibility  is  abolished,  anfesthesia, 
motor  paralysis,  loss  of  reflex  excitability  and  electro-muscular  contractil- 
ity are  observed.  This  succession  of  symptoms  is  noticeable  in  compres- 
sion of  the  trigeminus  by  certain  cerebral  tumors,  and  in  paralysis  of  the 
facial  from  caries  of  the  temporal  bone.  The  destructive  ophthalmia  due 
to  atrophy  of  the  trigeminus  has  been  studied  upon  page  117. 

With  regard  to  treatment,  it  will  suffice  to  state  that  it  must  be 
chiefly  directed  against  the  affection  to  which  the  atrophy  is  due.  This 
should  be  subjected,  as  far  as  possible,  to  appropriate  treatment  before 
it  has  terminated  in  atrophy.  If  the  nerve  is  already  in  such  condition, 
there  is  little  hope  of  improvement. 


b.  Neoplasms  of  the  Nerves  and  Neuromata. 

After  a  solution  of  continuity  in  the  nerves,  a  regeneration  of  the 
nervous  tissue  has  been  observed,  both  experimentally  and  clinically,  and 
has  been  referred  to  in  the  preceding  chapter  on  traumatic  nerve  lesions. 
A  swelling  en  masse  sometimes  forms  in  the  nerve-trunks  of  amputa- 
tion stumps,  during  the  stage  of  cicatrization,  and  becomes  excessively 
sensitive  to  contact,  the  pains  being  referred  to  the  amputated  part  (sen- 
sation of  the  integrity  of  amputated  limbs).  Wedl  has  observed  a  roll- 
ing in  of  new-formed  nerve-fibres,  which  has  been  called  cicatricial  neu- 
roma by  Lebert.  Virchow  has  noticed  the  development  of  nerve-fibres  in 
pleural  exudations;  Rokitansky  and  Virchow  have  seen  multiplication  of 
the  nervous  ganglia  in  ovarian  tumors.  In  the  so-called  proliferation  of 
the  connective  tissue  of  the  nerves,  a  transparent,  colloid  matter,  which 
is  at  first  gelatinous  and  then  becomes  horny,  is  deposited  in  the  nervous 
substance.  This  change  is  called  colloid  degeneration;  it  chiefly  affects 
the  nerves  in  their  intracranial  course,  more  rarely  those  which  start  from 
the  spinal  system,  and  extends  from  the  periphery  towards  the  centre  or 
vice-versa. 

Pseudo-neurom.ata  must  also  be  mentioned  among  the  neoplasms  de- 
veloping in  nerves.  They  form  more  or  less  circumscribed  tumors,  vary- 
ing from  the  size  of  a  millet-seed  to  that  of  an  egg,  hard,  elastic,  usually 
movable  with  the  nerve,  and  very  sensitive  to  pressure.  They  appear  to 
represent,  in  general,  a  connective-tissue  formation,  starting  from  the 
normal  interstitial  tissue  or  from  the  sheaths  of  the  nerve-bundles,  and, 
at  times,  contain  cysts  filled  with  colloid  matter.  In  the  majority  of 
cases  the  neuroma  is  situated  upon  the  side  of  the  nerves,  or  it  springs 
from  the  inner  portion  of  the  nerve  and  separates  the  nerve-fibres  from 
one  another  in  the  form  of  a  rosette.  The  tumors  which  develop  at  the 
expense  of  the  neurilemm.a  may  be  either  myxomata,  lipomata,  fibro- 
mata, or  diathetic  tumors.  True  neuromata  are  much  rarer;  according  to 
Virchow,  they  contain,  in  addition  to  a  network  of  connective  tissue,  bun- 
dles of  nerve-fibres  running  in  the  same  direction. 
Vol.  IL— 12 


178  CLINICAL   TEEATISE    ON 

The  spinal  nerves  are  the  most  frequent  site  of  neuromata  ;  they  are  much  rarer 
upon  the  cranial  and  sympathetic  nerves.  J"hese  nerve  tumors  are  usually  isolated, 
though  several  small  ones  are  sometimes  found  upon  one  nerve.  In  a  fresh  prepara- 
tion, taken  from  an  old  woman  and  presented  before  the  Vienna  Medical  Society  by 
Klob,  the  majority  of  the  nerve-truaks  were  covered  by  neuromata  arranged  like  a 
wreath  of  roses,  and  varying  from  the  size  of  a  hazel-nut  to  that  of  a  hen's  egg^  al- 
though no  noteworthy  symptoms  were  produced  during  life.  Analogous  examples  of 
chains  of  neuromata  have  been  observed  and  described  by  Smith,  Maher,  Payen, 
Kupferberg,  and  very  recently  by  Heller  (Virch.  Arch.,  44.  Bd.). 

We  still  know  very  little  concerning  the  etiology  of  neuromata.  Com- 
pression, traumatism,  or  rheumatic  influences  have  usually  been  regarded 
as  the  causes  of  the  inflammatory  irritation  and  neoplasm.  Solitary  neu- 
romata are  much  more  frequent  in  women.  Age  appears  to  play  only  a 
secondary  part  in  their  production. 

Among  the  symptoms  of  neuromata  we  must  especially  refer  to  the 
acute  neuralgic  pain  which  is  present  while  the  neuroma  is  still  in  a 
latent  condition.  In  the  nerve  tumors,  to  the  characteristic  signs  of  which 
we  have  previously  alluded,  the  pain  appears  in  the  form  of  paroxysms, 
which  become  more  and  more  frequent  and  are  readily  produced  by  com- 
pression or  simple  contact.  Compression  causes  the  pain  to  irradiate 
along  the  peripheral  course  of  the  nerve,  and  is  accompanied  by  a  sensa- 
tion of  numbness  and  formication,  rarely  by  symptoms  of  motor  irritation 
(contractions,  tremor,  contracture)  or  by  phenomena  of  depression  (an- 
aesthesia and  paresis).  Extensive  neuralgias  and  partial  or  general  con- 
vulsions sometimes  develop  as  reflex  phenomena. 

When  the  neuromata  occupy  the  superficial  parts,  they  are  accessible 
to  exploration  when  the  nerve-trunks  are  examined,  and  are  distinguished 
from  cancer  of  the  nerves  by  their  mobility,  the  possibility  of  displacing 
them,  and  their  gradual  development  without  general  symptoms. 

Various  forms  of  cancer  develop  at  the  periphery  of  the  nerves,  either 
primarily  or  secondarily,  and  are  accompanied  by  pain.  The  tumors 
adhere  to  the  surrounding  parts,  proliferate  rapidly,  ulcerate,  and  are 
accompanied  by  infiltration  of  the  lymphatic  glands,  cachexia,  and  com- 
plete paralysis  of  sensation  or  motion. 

Neuromata  almost  always  run  a  chronic  course.  They  do  not  threaten 
life  directly,  but  react  unfavorably  upon  the  general  condition  by  the 
violence  of  the  pains,  the  insomnia,  and  the  digestive  disorders  to  which 
they  give  rise.  Treatment  is  chiefly  of  a  surgical  nature.  Resorbents 
and  nervines  are  useless,  and  narcotics  only  produce  momentary  relief. 
Extirpation  constitutes  the  most  efficient  means  of  treatment,  and,  in  re- 
moving the  tumor,  the  nerve-fibres  should  be  injured  as  little  as  possible. 
If  we  are  forced  to  include  a  portion  of  the  nerve  in  the  operation,  a  cor- 
responding functional  disorder  will  be  produced  at  the  periphery.  Re- 
lapses sometimes  occur.  When  multiple  neuromata  are  present,  we  can 
only  remove  one  or  the  other  of  the  painful  tumors  with  the  bistoury. 


c.  Inflammation  of  the  Nerves  (Neuritis). 

The  simple  hyperaemias  and  slight  ecchymoses,  which  are  found  in  the 
sheaths  of  the  nerves  in  various  acute  and  diathetic  affections  (at  times 
mere  cadaveric  hyperfemia),  are  not  sufficiently  intense  to  be  regarded  as 
evidences  of  inflammation.  Apart  from  the  redness,  the  loss  of  substance, 
relaxation,  and  infiltration  of  the  neurilemma,  the  inflamed  nerve  appears 


DISEASES    OF   THE    KEßVOITS    SYSTEM.  179 

injected  and  swollen,  and  a  serous,  gelatinous,  or  fibrinous  exudation  is 
situated  between  the  different  bundles  of  fibres.  The  nerve-fibres  are 
only  affected  with  fatty  degeneration  after  the  inflammation  has  lasted 
for  a  certain  length  of  time.  We  also  know,  from  the  recent  experiments 
of  Hjelt  (loc.  cit.)  upon  artificial  neuritis,  that  the  inflammator}'  irritation  is 
accompanied  by  nuclear  proliferation  and  by  coagulation  and  fatty  degen- 
eration of  the  nerve-fibres. 

The  inflammation  of  the  nerves  usually  starts  from  the  connective-tis- 
sue layer  of  the  neurilemma,  and  the  myeline  is  only  secondarily  affected. 
The  inflammatory  process  constitutes  a  perineuritis  or  an  interstitial  neu- 
ritis, according  to  the  degree  of  hyperplasia  and  the  abundance  of  the 
nuclei  in  the  external  or  internal  nerve-sheaths,  and  according  to  the  nu- 
clear proliferation  and  fibrillary  thickening  w-hich  may  develop  in  the 
sheath  of  Schwann. 

The  exudation  produced  by  the  inflammation  may  be  absorbed,  in 
slight  cases,  before  the  nerve-fibres  have  undergone  any  permanent 
changes.  When  the  inflammation  follows  a  chronic  course,  the  sheath  of 
the  nerves  becomes  thickened,  fibrous,  and  resisting,  and  is  frequently 
adherent  to  the  adjacent  tissues.  The  nervous  substance  remains  intact 
in  slight  forms,  but  in  severe  cases  it  undergoes  atrophy  from  the  com- 
pression exercised  by  the  exudation.  If  the  exudation  becomes  organized, 
it  will  result  in  the  formation  of  connective  tissue,  vrith  thickening  and 
sclerosis  of  the  nerves  and  disappearance  of  the  nerve  elements.  In  trau- 
matic inflammations,  and  in  the  suppurations  which  are  propagated  to  the 
nerves  ^^er*  contiguitatem,  purulent  infiltration  and  necrosis  of  the  nervous 
tissue  may  develop. 

Pain  constitutes  one  of  the  most  important  symptoms  of  neuritis.  It 
is  usually  continuous,  rarely  remittent  or  even  intermittent;  it  is  increased 
by  pressure  and  motion  (as  Virchow  has  shown),  though  this  symptom  is 
not  sufficient  evidence  of  neuritis.  The  pain  is  not  only  present  in  the 
infliamed  part,  but  it  also  radiates  towards  the  periphery,  and  is  accom- 
panied by  formication  and  numbness.  Fever  is  only  present  in  extensive 
neuritis.  If  the  exudation  increases  or  compresses  the  nerves  for  a  long 
time,  the  initial  symptoms  of  irritation  (hyperfpsthesia,  painful  irradia- 
tions, subsultus)  are  followed  by  antesthesia  and  paralysis.  The  paral- 
yses of  motion  and  sensation  are  complicated  by  trophic  disturbances  in 
the  muscles,  and  sometimes  in  the  skin  (herpetic  eruptions)  and  articula- 
tions;, these  are  also  the  sequences  of  inflammatory  irritation  of  the 
nerves.  Anaesthetic  lepra  (elephantiasis  Gra^corum)  also  results,  accord- 
ing to  Virchow  (Die  krankh.  Geschw.,  II.  Bd.,  18G4— '65),  from  a  peri- 
neuritis with  cellular  proliferation  between  the  nerve-tubes.  According 
to  Boeck  and  Danielssen  (Traite  de  la  Spedalsked.,  1848),  and  to  the  more 
recent  observations  of  Steudener  (Beitr.  z.  Path,  der  Lepra,  1867),  the 
inflammatory  process  may  extend  from  the  peripheral  nerves  to  the  nerve- 
roots  and  even  to  the  cord  (formation  of  canaliculi  in  the  gray  substance, 
Steudener).  We  have  also  seen  that  reflex  paralysis  may  be  caused  by 
the  extension  of  ascending  neuritis  to  the  cord,  as  has  been  rendered 
probable  by  the  previously  mentioned  experiments  of  Tiesler  and  Fein- 
berg  (loc.  cit.). 

From  a  diagnostic  point  of  view,  neuritis  is  distinguished  from  neural- 
gia by  the  continued  character  of  the  pains,  which  rarely  present  remis- 
sions or  intermissions,  by  the  absence  of  circumscribed  puncta  dolorosa, 
by  the  peculiar  sensibility  of  the  nerves  to  electrical  irritation  (especially 
to  the  induced  current),  and  by  the  secondary  phenomena  of  muscular 


180  CLIiaCAL   TEEATISE   ON 

atrophy  and  motor  and  sensory  paralysis.  As  a  rule,  neuritis  is  only  de- 
tected after  long  and  careful  observation. 

Muscular  rheumatism,  which  is  often  very  painful,  is  recognized  by  its 
diffuse  character,  by  the  absence  of  other  peripheral  symptoms,  and  b\' 
the  fact  that  the  pains  are  intensified  rather  by  movements  than  by  pres- 
sure. The  diseases  of  the  vessels  which  accompany  the  nerves  are  char- 
acterized by  the  sudden  pain,  absence  of  pulsation,  depression  of  tempera- 
ture, abolition  of  sensibility  and  nutrition  (arterial  embolism),  the  appre- 
ciable induration  of  the  veins,  the  extensive  oedema  and  concomitant  ve- 
nous stasis  (venous  thrombosis).  These  phenomena  are,  therefore,  not 
readily  mistaken  for  neuritis. 

The  etiology  of  inflammation  of  the  nerves  is  variable.  An  intense 
rheumatic  influence,  traumatic  lesions,  compression,  and  inflammation  and 
suppuration  in  the  vicinity  of  the  nerves  may  give  rise  to  neuritis.  At  a 
later  period  the  neuritis  may  terminate  by  prompt  absorption  of  the  exu- 
dation. In  the  unfavorable  cases,  in  which  it  pursues  a  chronic  course,  it 
terminates  in  more  or  less  severe  disturbances  of  motion  and  sensation. 

In  the  treatment  of  inflammation  of  the  nerves,  it  is  advisable  to  resort, 
from  the  beginning,  to  the  employment  of  antiphlogistics.  Good  results 
are  often  obtained  from  local  bleeding,  cold  compresses,  prolonged  tepid 
baths  (with  the  necessary  precautions  upon  entering  and  leaving  the  bath). 
I  can  also  recommend  the  use  of  moist  packs,  continued  until  the  return  of 
warmth  to  the  body,  and  followed  by  half-baths  of  24:°-20°  C.  (five  to  eight 
minutes).  When  the  pain  is  violent  we  may  resort  to  hypodermic  injec- 
tions of  morphine  in  remote  parts.  Iodide  of  potassium  is  prescribed  in 
chronic  cases,  but  iodated  baths,  the  indifferent  thermal  waters,  and  mud- 
baths  have  a  much  more  positive  action  in  producing  absorption  of  the  in- 
flammatory products.  The  secondary  disorders  of  motion  and  sensation 
are  best  combated  by  means  of  electricity  (galvanization  of  the  nerves 
and  faradization  of  the  muscles).  This  can  be  advantageously  combined 
with  hydrotherapeutic  or  thermal  treatment. 


d.  Neuralgia. 

The  term  neuralgia  includes  those  pains  which  appear  in  the  various 
segments  of  the  nerves,  from  their  origin  to  the  periphery,  and  which 
usually  develop  in  paroxysms,  either  spontaneously  or  after  pressure  upon 
certain  points.  The  production  of  pain  requires  that  a  feeble  stimulus 
should  react  very  quickly  upon  the  nerve-fibres,  though  a  violent  irritation 
may,  by  its  intensity,  replace  the  slowness  of  propagation.  Nutritive 
disturbances  in  the  myeline  (sometimes  secondary  to  disorders  of  circula- 
tion) may  also  cause  painful  sensations.  The  latter  are  usually  regulated 
by  the  primary  intensity  or  the  increase  of  the  exciting  cause,  by  the 
duration  of  the  irritation,  and  by  the  degree  of  exhaustion  of  the  nerves. 
According  to  Schiff's  experiments,  the  receptivity  to  stimuli,  but  not  the 
conducting  power,  is  increased  in  hyperaemic  nerves.  The  periodical  return 
of  neuralgia  may  be  due  to  the  fact  that  the  internal  organic  stimuli  act 
at  intervals.  The  exhaustion  of  the  exaggerated  nervous  activity  may  be 
caused  by  a  diminution  either  in  the  receptivity  of  the  irritated  point,, 
of  the  conductibility  of  the  fibres,  or  of  the  central  perception. 

As  the  nerve-fibres  which  are  distributed  to  the  skin  enter  the  nerve- 
trunks  from  the  exterior  at  different  heights,  compression  or  other  irrita- 
tions of  the  nerves  will  affect  the  external  fibres  earlier  than  the  internal. 


DISEASES    OF   THE    NERVOUS    SYSTEM.  181 

It  therefore  follows  that  the  pain  appears  to  run  along  the  course  of  the 
nerves  from  above  downwards.  The  lancinating  pains  along  the  nerve- 
trunks  are  especially  produced  under  the  influence  of  rapidly  acting,  strong 
stimuli,  such  as  occur  in  sudden  shocks  to  the  elbow,  or  from  the  effects 
of  intense  cold. 

The  arrangement  of  the  central  mosaic  determines  the  law  of  peripheral 
manifestations.  An  irritation  of  the  intra-medullary  sensory  fibres  in  the 
gray  columns  will  be  transformed  into  painful  sensations  in  the  terminal 
expansions  of  the  nerves.  The  posterior  roots  of  the  spinal  nerves,  the 
numerous  sensory  filaments  situated  between  the  external  integument  and 
the  aponeuroses,  and  penetrating,  in  part,  into  the  muscles,  also  furnish 
weak  points  which  may  give  rise  to  neuralgias  in  the  vast  network  of  the 
peripheral  nervous  system. 

When  the  irritation  is  situated  centrally,  we  can  readily  understand 
why  the  terminal  nervous  apparatus,  which  is  affected  with  intermittent 
pains,  does  not  present  any  morbid  change.  Tissue  changes  are  some- 
times observed  in  peripheral  affections  of  the  sensory  nerves.  Under  this 
head  we  may  mention  :  swelling  of  the  nerves  and  granular  opacity  of 
the  myeline,  with  periostitis  of  the  osseous  orifices  (supra-orbital,  infra- 
orbital, inferior  alveolar,  mental  nerves,  etc.);  thickening  of  the  sheaths 
of  the  nerves  from  inflammation  of  the  surrounding  parts;  proliferation  of 
the  connective  tissue  between  the  nerve-bundles,  and  of  cancer-cells  be- 
tween the  nerve-fibres  (as  in  a  case  which  I  shall  report  under  the  head  of 
sciatica);  the  nodular  swellings  of  the  nerves  in  amputation  stumps,  which 
may  give  rise  to  neuralgia;  finally,  to  this  category  belong  the  neuralgias 
dependent  upon  the  compression  exercised  by  adjacent  tumors,  vertebral 
affections,  and  venous  stases  in  the  nervous  tissues.  We  shall  again  refer 
to  these  particulars  in  treating  of  special  neuralgias. 

Pain  constitutes  the  chief  phenomenon  among  the  symptoms  of  neural- 
gia. In  the  majority  of  cases  it  follows  the  anatomical  course  of  the  nerves, 
and  appears  under  the  form  of  paroxysms,  which  may  be  separated  from 
one  another  by  complete  intermissions,  or  merely  by  remissions.  The 
patients  describe  the  pain  as  shooting  (with  or  without  cutaneous  hyper- 
jesthesia),  tearing,  piercing,  pricking,  burning,  etc.  Facial  neuralgia  and 
ataxia  dolorosa  are  the  forms  which  give  rise  to  the  most  violent  paroxysms. 
Certain  points  frequently  constitute  the  site  of  the  pains  from  which  the 
patients  suffer.  They  may  also  be  propagated  to  other  branches  of  the 
nerve-roots,  and  almost  always  radiate  from  the  centre  to  the  periphery, 
though  sometimes  in  the  opposite  direction. 

Valleix  first  discovered  the  puncta  dolorosa  which  form  such  an  impor- 
tant characteristic  of  neuralgia.  They  are  most  frequently  found  at  the 
points  at  which  the  nerves  emerge  from  their  bony  canals  in  order  to 
spread  over  the  surface  of  bones,  when  they  pass  through  aponeurotic  or 
muscular  orifices,  or  in  the  regions  in  which  important  cutaneous  nerves 
anastomose  with  one  another.  As  a  rule,  they  constitute  circumscribed 
painful  spots,  which  may  be  discovered  by  careful  exploration  upon  press- 
ing with  the  finger  along  the  course  of  the  nerves;  they  are  present  in 
the  majority  of  neuralgias.  But  there  are  some  cases  (and  I  have  fre- 
quently observed  such)  in  which  the  puncta  dolorosa  only  appear  during 
the  paroxysms  and  are  absent  at  other  times.  In  doubtful  cases  I  have 
often  discovered,  by  means  of  electrical  exploration,  certain  points  along  the 
nerves  which  were  very  sensitive  to  the  electrical  current  (continuous  or 
induced),  while  other  portions  of  the  same  nerve  or  corresponding  parts 
on  the  healthy  side,  were  not  especially  affected  by  the  current.     The 


182  CLINICAL    TREATISE    ON" 

pains  in  neuralgia  may  also  extend,  secondarily,  to  other  nerve-filaments 
(originating  in  the  same  roots),  or  may  even  be  propagated  by  irradiation 
to  remote  parts  in  cases  of  extreme  irritability  of  the  nervous  system. 

Tuerck  had  observed  hyperesthesia  or  anaesthesia  in  certain  neuralgias,  and  Noth- 
nagel (Virch.  Arch.,  54.  Bd. )  has  more  recently  shown  that  these  phenomena  habitu- 
ally accompany  neuralgias  of  the  limbs  and  of  the  superficial  nerves  of  the  trunk  and 
head.  Cutaneous  hyperalgef'ia  is  found  at  the  onset  of  the  attack  (from  two  to  eight 
weeks),  but  later  the  sensibility  of  the  skin  is  diminished.  Both  symptoms  are  ob- 
served upon  all  the  corresponding  nerve  fibres,  or  they  may  extend  to  the  entire  half 
of  the  body  (Tuerck),  and  disappear  during  the  course  of  recovery.  According  to 
Nothnagel,  the  hypersesthesia  results  from  an  irradiation  of  the  stimuli  to  a  large 
number  of  sensory  nerve-cells ;  the  auEesthesia  is  caused  by  the  exhaustion  of  the 
nerve-celJs,  following  excessive  stimulation.  In  many  of  my  cases  these  sensory  dis- 
orders were  evidently  due  to  vaso-motor  irritation. 

Neuralgias  are  not  infrequently  accompanied  by  peculiar  reflex  symp- 
toms, which  are  explained  by  the  numerous  communications  of  the  pos- 
terior root-fibres  with  the  gray  substance  of  the  cord.  In  facial  neural- 
gia we  will  find  that  contractions  of  the  muscles  of  the  face  follow  the 
sensory  irritation  ;  in  neuralgia  of  the  limbs  the  latter  are  the  seat  of 
more  or  less  extensive  muscular  spasms.  The  rhythm  of  the  movements 
of  the  heart  and  of  respiration  may  also  be  changed.  In  rare  cases,  pre- 
existing muscular  spasms  are  replaced  by  neuralgia  (as  sometimes  occurs 
in  the  irritative  stage  of  ataxia).  The  depression  of  the  reflex  power 
may  thus  lead  to  the  absence  of  Goltz's  phenomenon,  when  the  irritation 
of  the  intestines  (which,  under  other  circumstances,  will  produce  arrest 
of  the  heart's  action  through  the  medium  of  the  pnoumogastric)  is  com- 
bined with  intense  irritation  of  the  sensory  nerves  of  the  limbs.  Finally, 
we  must  also  classify,  among  the  reflex  acts,  the  vaso-motor  disturbances 
produced  by  irritation  of  the  sympathetic  nerve-fibres  (which  are  inter- 
mingled with  sensory  fibres).  These  include  the  anomalies  of  circulation 
and  secretion  which  are  observed  in  neuralgias,  the  cutaneous  eruptions, 
and  the  disorders  of  nutrition  (as  in  prosopalgia). 

The  etiology  of  neuralgia  is  involved  in  considerable  obscurity.  Its 
causes  vary  considerably,  being  sometimes  general,  sometimes  local. 
Among  the  general  causes  the  most  important  is  the  abnormal  excitabil- 
ity of  the  nervous  system,  either  in  the  central  organs  or  in  the  periph- 
eral expansions;  it  may  be  hereditary  or  produced  by  external  influences. 
Experience  has  shown  that  fathers,  suffering  from  nervous  affections, 
frequently  transmit  to  their  sons  a  certain  predisposition  to  nervous  dis- 
orders and  to  neuralgia.  In  the  same  manner,  mothers,  who  are  affected 
with  neuralgias  of  the  head,  rachialgia,  cardialgia,  etc.,  transmit  this  pre- 
disposition to  their  daughters.  But  I  do  not  believe  that  we  can  admit 
the  hypothesis  hazarded  by  Anstie  (Neuralgia  and  Diseases  that  Resem- 
ble It,  London,  1871),  who  presupposes  an  hereditary  weakness  of  the 
nerve-cells  of  the  posterior  columns,  which,  after  prolonged  centripetal 
irritation,  leads  to  interstitial  atrophy  of  these  cells,  terminating  either  in 
recovery  (?)  or  in  degeneration. 

Sex  possesses  a  certain  influence,  in  the  sense  that  some  neuralgias  (intercostal, 
lumbo-abdomiual)  are  most  frequently  observed  in  females,  while  sciatica  is  most  fre- 
quent in  men.  Until  the  age  of  thirty  years,  women  are  usually  more  exposed  to 
neuralgia  than  men,  a  fact  which  may  be  attributed,  in  great  part,  to  the  sexual  con- 
ditions (menstruation,  chlorosis,  pregnancy). 

The  season  of  the  year  a,nd  changes  in  temperature  have  a  positive  influence  upon 
the  appearance  of  neuralgias.     In  a  third  of  the  cases  collected  by  VaUeix  and  other 


DISEASES    OF   THE    NERVOUS    SYSTEM.  183 

authors,  the  invasion  of  the  disease  occurred  during  the  cold  or  changeable  months  of 
the  year.  Wind,  moist  cold,  chilling  of  the  body  while  perspiring,  may  only  affect  the 
peripheral  nerve  terminations,  or  may  transmit  theii*  action  to  the  central  fibres  along 
the  trunks  and  nerve-roots,  thus  giving  rise  to  excentric  neuralgias.  The  develop- 
ment or  return  of  neuralgias  is  frequently  caused  by  residence  in  moist,  cold  houses, 
and  living  in  a  locality  which  is  exposed  to  the  winds.  Finally,  the  neuralgias  ob- 
served by  Guensburg  and  Leudet  (Arch.  Gen.,  fev.,  1864),  in  certain  cases  of  phthisis 
and  chlorosis,  result  from  the  effect  of  vitiated  blood  upon  the  nervous  system. 

The  local  causes  of  neuralgia  are  either  central  or  peripheral.  The 
central  causes  proceed  from  the  brain  or  cord.  Among  the  cerebral  af- 
fections, certain  congestive  conditions  (those,  for  example,  which  precede 
apoplexy)  may  be  attended  with  neuralgias;  or  the  latter  may  form  a 
concomitant  symptom  of  inflammation,  tumors,  sclerosis,  or  softening. 
Spinal  affections  very  often  assume,  at  the  onset,  the  appearances  of  vague 
neuralgias.  Lancinating  pains  with  cutaneous  hyperaesthesia  are  a  fre- 
quent initial  symptom  of  ataxia.  Spondylitis  of  the  upper  segment  of 
the  vertebral  column  is  also  accompanied,  at  the  onset,  by  neuralgia  of 
the  cervical  and  brachial  plexuses  and  of  the  intercostal  spaces.  A  large 
number  of  hysterical,  dyscrasic,  and^toxic  neuralgias  may  also  be  ranged 
in  this  category. 

Among  the  peripheral  causes  may  be  mentioned  :  local  lesions  of  the 
nerves  or  of  their  sheaths,  following  traumatism,  compression,  laceration, 
inflammation;  periostitis  and  caries  of  the  adjacent  bones,  and  especially 
of  the  bony  orifices  through  which  the  nerves  pass;  rheumatic  affections 
of  the  articular  and  muscular  nerve-fibres;  stases  in  the  venous  channels 
adjoining  the  nerves,  and  atheroma  of  the  arteries;  compression  of  the 
nerves  by  aneurisms,  degenerated  glands,  neoplasms,  syphilitic  gummata, 
inflammation  and  enlargement  of  internal  organs,  and  foreign  bodies. 
In  all  these  cases  the  character  of  the  inflammatory  or  mechanical  irrita- 
tion, and  the  nature  of  the   tumors,  influence   the  neuralgic  phenomena. 

At  a  later  period  we  will  discuss  the  neuralgias  which  develop  from 
reflex  agencies  and  from  irradiation. 

The  diagnosis  of  neuralgias  is  usually  less  difficult  than  their  locali- 
zation. Pains  which  follow  the  course  of  the  nerves,  which  recur  parox- 
ysmally,  and  which  present  certain  puncta  dolorosa,  point  to  the  neural- 
gic character  of  the  affection.  In  the  absence  of  these  various  condi- 
tions, we  can  only  diagnose  neuralgia  with  more  or  less  probability. 

As  neuralgia  is  almost  always  symptomatic  of  various  morbid  condi- 
tions, the  most  important  question,  from  a  clinical  stand-point,  is  to  dis- 
cover the  primary  source  of  the  neuralgic  symptoms.  In  this  respect  we 
may  state  that  it  is  a  useless  labor  to  divide  neuralgias,  as  do  some 
authors  of  the  present  day,  into  artificial  groups,  which  rest  more  upon 
personal  views  than  upon  real  objective  signs. 

In  dealing  with  neuralgia,  the  physician  should,  above  all,  deter- 
mine, both  with  regard  to  prognosis  and  treatment,  whether  it  is  merely 
the  expression  of  a  local  irritation,  or  the  peripheral  indication  of  cen- 
tral morbid  processes.  In  the  majority  of  cases  it  is  possible,  by  a 
careful  consideration  of  the  other  morbid  phenomena,  to  form  an  opinion 
concerning  the  nature  of  the  neuralgia.  It  is  sometimes  necessary  to  ob- 
serve for  a  long  time  the  manner  of  development  of  the  disease  in  order 
to  collect  sufficient  data;  it  is  only  in  very  rare  cases,  however,  that  the 
primary  cause  of  the  neuralgia  completely  escapes  us  during  life.  We 
shall  now  point  out  the  most  striking  and  characteristic  symptoms  of  this 
affection. 


184  CLINICAL   TREATISE    ON 

Neuralgias  of  cerebral  origin  are  accompanied  by  headache  (especially 
in  the  forehead  and  temples);  they  develop  upon  one-half  of  the  body, 
and  appear  as  tearing  pains  along  the  course  of  certain  nerves  (as  in 
prosopalgia),  with  reflex  contractions  in  the  face,  and  general  hyperaes- 
thesia  or  psychical  symptoms.  The  neuralgias  which  are  symptomatic  of 
cerebral  tumors  (facial  neuralgia,  fixed  or  wandering  pains  in  the  neck, 
pains  in  the  limbs)  are  characterized  by  periodical  cephalalgia,  vertigo, 
trigeminal  neuralgia,  followed  by  ana?sthesia,  by  the  appearance  of  con- 
vulsions, early  signs  of  neuroretinitis,  paresis  of  various  cranial  nerves, 
and,  at  a  later  period,  paralysis  in  the  extremities.  Spinal  neuralgias  are 
almost  always  preceded  by  early  parresthesiie  (sensations  of  cold,  formi- 
cation in  the  fingers  and  toes,  numbness).  Periodical  brachialgia  or 
rachialgia,  with  painful  sensations  in  the  back,  and  in  one  or  the  other 
leg  (lancinating  pains  in  the  sciatic  nerve,  with  cutaneous  hypertesthesia 
at  the  beginning  or  during  the  course  of  the  ataxia);  intercurrent  diplo- 
pia, marked  inequality  of  the  pupils;  ready  fatigue;  coexisting  genital 
irritation;  extreme  sensibility  to  winds  and  moisture;  abnormal  excitabil- 
ity to  the  galvanic  current  in  certain  definite  spots:  these  are  the  symp- 
toms which  evidence  the  spinal  origip  of  neuralgias. 

Hysterical  neuralgias  usually  appear  after  mental  excitement  or  hys- 
terical convulsions.  They  are  recognized  by  their  rapid  modifications  as 
regards  situation  and  intensity,  and  by  the  coexistence  of  other  motor  and 
sensory  disturbances  (for  further  details,  vide  page  41,  Vol.  I.).  Hysteri- 
cal neuralgias  are  of  cerebral  or  spinal  origin,  but  rarely  of  a  peripheral 
nature.  Mercurial  and  lead  neuralgias  are  almost  always  of  peripheral 
origin,  and  are  recognized  by  the  other  symptoms  and  by  the  antecedents 
of  the  patient.  Aufemic  neuralgias  which  sometimes  develop  in  tuber- 
culosis, chlorosis,  and  intermittent  fever  are  due  to  the  influence  of  the 
vitiated  blood  upon  the  nervous  system,  and  are  readily  recognized  by 
the  ensemble  of  the  disease. 

Arthritic  neuralgias  are  only  observed  in  old  people,  and  are  accom- 
panied by  swelling  and  stiffness  of  the  joints;  the  influence  of  neuritis 
nodosa  upon  this  class  of  affections  has  not  been  hitherto  well  determined. 
Syphilitic  neuralgias  are  attributable  to  periostitis  or  osteitis.  For  the 
consideration  of  traumatic  neuralgias  we  refer  to  page  170,  Vol.  II.  Rheu- 
matic neuralgias  are  usually  limited  to  the  final  nerve  ramifications  in  the 
skin,  aponeuroses,  muscles,  and  joints,  and  they  result  from  the  effects  of 
cold.  Neuralgias  of  mucous  membranes,  such  as  the  urethra,  rectum, 
stomach  (gastralgia),  intestine,  abdominal  walls  (simulating  peritonitis) 
are  almost  always  concomitant  phenomena  of  central  affections  or  of  hys- 
terical seizures.  Finally,  pains  of  peripheral  origin  may  radiate  to  remote 
sensory  nerves,  and  may  give  rise,  in  case  of  abnormal  excitability  (in 
nervous  individuals  and  especially  in  females),  to  irradiated  neuralgias. 
To  this  category  belong  the  pain  in  the  shoulder  in  hepatic  colic,  the  dor- 
sal pain  in  cancer  of  the  stomach,  the  femoral  pains  in  renal  calculi,  etc. 

The  prognosis  of  neuralgia  depends  upon  the  primary  affection  to 
which  it  is  due.  The  peripheral  forms  may  recover,  in  certain  cases,  if 
the  patients  are  placed  under  appropriate  treatment.  AX  other  times,  on 
the  contrary  (as  in  certain  cerebral  and  spinal  affections),  they  offer  an 
obstinate  resistance  to  treatment,  and  we  are  forced  to  resort  to  mere 
palliative  measures.  Hysterical  and  toxic  neuralgias,  and  those  which 
are  due  to  anjemia,  grow  better  with  the  improvement  in  the  general 
condition.  Neuralgia,  caused  by  peripheral  diseases,  will  disappear  when 
the  source  of  irritation  to  which  they  are  due   has   disappeared.     As  a 


DISEASES    OF   THE    NERVOUS    SYSTEM.  185 

rule,  recent  neuralgias,  developing  in  young  subjects,  are  more  suscepti- 
ble of  recovery  than  the  chronic,  complicated  forms  affecting  old  people. 
The  frequency  of  relapses  in  neuralgia  is  universally  known,  and  the 
persistence  of  pxincta  dolorosa  is  premonitory  of  a  return  of  the  disease. 

In  the  treatment  of  neuralgias  especial  attention  must  be  paid  to  the 
removal  of  the  cause.  But,  as  a  rule,  it  is  much  easier  to  discover  the 
cause  than  to  effect  its  removal.  In  the  majority  of  cases  we  must  en- 
deavor to  relieve  the  morbid  excitability  of  the  nerves  as  much  as  possi- 
ble, or  to  suppress  their  conducting  power  (as  in  prosopalgia).  Fre- 
quently this  purpose  is  but  partially  effected,  and  it  only  remains  for  the 
physician  to  procure  for  his  patient  at  least  some  relief,  some  moments 
of  repose  in  the  midst  of  the  despairing  monotony  of  his  pains.  In 
rheumatic  neuralgias,  rapid  improvement  is  obtained  by  the  immediate  use 
of  antiphlogistics,  diaphoretics,  vapor-baths,  moist  packs  (a  half  hour  to 
an  hour),  followed  by  cool  half-baths  and  the  electrical  current.  When 
the  disease  assumes  a  chronic  course,  we  must  continue  the  employment 
of  the  latter  measures  methodically  and  for  a  long  time,  as  well  as  the 
different  thermal  waters.  If  the  affection  is  due  to  anremia,  resort  may 
be  had  to  tonic  treatment  and  to  ferruginous  waters  (Franzenbad,  Spa, 
Pyrmont,  etc.);  iodide  of  potassium  maybe  administered,  if  periostitis 
is  suspected.  In  toxic  neuralgias  we  may  prescribe  warm  baths  and 
nutritious  diet,  and  stimulate  the  secretions. 

Palliative  treatment  consists  in  the  endeavor  to  diminish  the  abnormal 
excitability  of  the  nerves.  Among  the  new  remedies  employed  for  this 
purpose,  bromide  of  potassium  (two  to  four  grammes  daily)  sometimes 
renders  good  service.  In  periodical  neuralgia,  quinine  is  prescribed  in 
large  doses  (alone  or  combined  with  opiates),  or  Fowler's  solution. 
Opium  internally  and  preparations  of  hydrocyanic  acid  are  poorly  toler- 
ated by  many  patients;  they  very  often  produce  severe  gastralgic  symp- 
toms, and  their  sedative  action  is  very  slow.  In  such  cases  preference 
must  be  given  to  subcutaneous  injections  of  morphine,  extract  of  opium, 
atropine,  etc.,  although  they  usually  possess  only  temporary  efficacy,  and 
permanent  recoveries  are  exceptional. 

If  we  desire  to  combine  morphine  and  quinine  for  hypodermic  use,  we  must  em- 
ploy aqueous  solutions  of  the  hydrochlorate  of  morphine  and  bisulphate  of  quinine. 
I  have  shown  (Med.  Presse,  23,  1867)  that  a  mixture  of  concentrated  solutions  of 
acetate  of  morphia  and  bisulphate  of  quinia  will  give  rise  to  a  cheesy  precipitate  of 
the  insoluble  neutral  sulphate  of  quinia,  with  the  formation  of  the  sulphate  of  mor- 
phia and  hydrated  acetic  acid  (according-  to  the  law  of  double  substitutions).  The 
severe  accidents  which  Nussbaum  has  observed  upon  himself  from  the  use  of  these 
injections  (intense  pruritus  over  the  entire  body,  redness  of  the  face,  tinnitus  aurium, 
flashes  of  light,  pulse  of  one  hundred  and  fifty  to  one  hundred  and  seventy)  are  ex- 
ceedingly rare  occurrences. 

The  endermic  administration  of  opiates  is  little  used  on  account  of 
the  numerous  inconveniences  connected  with  it;  ointments  containing 
veratrine  and  aconitine  (0.05-0.15  mixed  with  fat)  are  sometimes  use- 
ful. Flying  blisters  (Valleix)  are  especially  successful  in  acute  rheu- 
matic neuralgias.  Local  anaesthesia  (Richardson)  and  inhalations  of 
chloroform  only  produce  an  effect  during  the  period  of  application. 
Bernatzik's  liquid  (chloroform  eighteen  grammes,  acetate  of  morphia  0.2 
grammes,  rectified  alcohol  0.8  grammes)  acts  favorably  in  neuralgia 
of  the  dental  nerves  (prolonged  friction  over  the  painful  points),  but  only 
for  a  certain  length  of  time. 

Electricity  has  been  largely  employed  in  recent  times,  and  has  proved 


186  CLINICAL   TREATISE    ON 

successful  in  a  considerable  number  of  cases.  But  complicated,  exten- 
sive, and  old  central  affections  sometimes  resist  all  electrical  treatment. 
In  practising  faradization,  the  secondary  current  is  most  frequently  em- 
ployed, the  electrical  brush  being  placed  along  the  course  of  the  nerves. 
In  using  the  continuous  current  (which  merits  the  preference  on  account 
of  its  less  tension)  the  anode  is  applied  as  closely  as  possible  to  the  cen- 
tres, and  the  cathode  upon  the  painful  points  (sittings  of  three  to  four 
minutes  with  moderate  currents,  the  intensity  of  which  may  be  gradually 
increased).  In  spinal  neuralgias,  galvanic  currents  are  passed  through 
the  vertebral  column,  and  stabile  currents  through  the  nerve-trunks.  In 
cerebral  forms,  weak  currents  are  applied  locally,  or  they  are  made  to 
traverse  the  head  through  the  inedium  of  the  mastoid  processes.  In  basi- 
lar and  arthritic  neuralgias,  certain  authors  recommend  the  galvanization 
of  the  cervical  sympathetic  nerves. 

B"  means  of  hydrotherapeutic  treatment  we  endeavor  to  diminish  the 
excess  of  local  or  general  sensibility,  and  to  soothe  the  erethism  of  the 
nerves  or  of  their  centres,  by  acting  upon  the  vast  sensory  network  of  the 
skin.  In  the  beginning  we  prescribe  half-baths  at  24°-22°  C,  and  gradually 
lower  their  temperature.  If  the  pains  are  intense,  we  may  combine  the 
baths  with  moist  packs  of  a  half  hour's  duration  and  with  dorsal  affusions; 
local  douches  should  only  be  employed  if  the  neuralgia  is  known  to  be 
peripheral.  In  neuralgias  of  central  origin,  care  must  be  taken  to  dimin- 
ish the  exciting  action  of  cold,  and  we  should  avoid  all  stimulating  meas- 
ures, taking  into  consideration  the  individual  conditions. 

Surgical  interference  frequently  constitutes  the  only  refuge  to  which 
the  patients  can  resort  for  the  relief  of  their  torments.  The  majority  of 
surgeons  favor  excision  of  a  considerable  portion  of  the  nerve  (neurec- 
tomy) in  order  to  prevent  the  reunion  of  the  two  ends  ;  according  to 
Bruns,  at  least  one  centimetre  of  the  nerve  must  be  excised.  Only  a  few 
modern  authors  (Stromeyer  and  O.  Weber)  advocate  simple  section  (neu- 
rotomy) of  the  nerves.  The  operation  is  indicated  when  the  neuralgia 
occupies  a  circumscribed  region,  when  it  is  due  to  compression,  or 
the  pains  are  very  intense  and  rebellious  (as  in  trigeminal  neuralgia). 
Although  excision  of  the  nerves  often  possesses  merely  a  temporary  util- 
ity, and  the  neuralgia  may  return  in  other  branches,  nevertheless  a  long 
suspension  of  the  pains  is  a  benefit,  the  value  of  which  the  patient  is  in  a 
better  condition  to  recognize  than  others. 


DISEASES    OF   THE    NEEVOÜS    SYSTEM.  187 


I.— DISEASES   OF  THE  CRANIAL  NERVES. 

In  studying  the  affections  of  the  cranial  nerves,  we  shall,  at  first, 
make  a  summary  review  of  certain  central  forms,  and  shall  then  pay  spe- 
cial attention  to  the  disorders  occurring  in  the  peripheral  course  o£  the 
nerves.  The  following  clinical  expose  of  the  disorders  affecting  the 
nerves  of  special  sense,  the  motor  and  the  mixed  cranial  nerves,  will  cor- 
respond to  the  three  fundamental  types  expressive  of  their  physiological 
functions. 


CHAPTER  XLIV. 

A. — Affections  of  the  Nerves  of  Special  Sense. 

Following  the  anatomical  order,  we  shall  refer  to  neuroses  of  the 
olfactory,  optic,  acoustic,  and  glosso-pharyngeal  nerves.  In  order  to 
avoid  repetition,  we  will  merely  call  attention  to  the  part  which  the  sen- 
sorial nerves  assume  in  the  central  affections  of  which  we  have  previously 
spoken,  and  will  direct  our  attention  chiefly  to  the  peripheral  diseases  of 
these  nerves. 

a.  Diseases  of  the  Olfactory  Nerve. 

The  principal  disorders  which  occur  on  the  part  of  these  nerves  are 
hvperresthesia  (hyperosmia)  and  anaesthesia  (anosmia).  Temporary  hy- 
peraesthesia  may  be  observed  in  certain  patients  who  have  become  ex^ 
tremelv  nervous  after  prolonged  diseases,  but  it  is  most  frequently  noticed 
in  hysterical  patients  and  in  the  insane.  In  the  latter  case,  in  which  sub- 
jective olfactory  sensations  exist,  softening  of  the  olfactory  nerve,  neo- 
plasms of  the  base  of  the  brain  extending  to  the  anterior  lobe,  softening 
or  discoloration  of  the  olfactory  bulb,  and  adhesions  of  the  olfactory 
nerves  to  the  dura  mater,  have  been  discovered.  In  a  case  reported  by 
Berard,  olfactory  sensations  had  existed  during  life,  despite  the  absence 
of  the  first  pair  of  nerves  (anomaly  of  central  perception  or  of  con- 
ductibility).  In  an  observation  recently  published  by  Sander  (Arch,  f. 
Psych,,  1873),  epileptiform  attacks  occurred  with  subjective  sensations  of 
taste,  and  the  left  olfactory  nerve  was  found  to  have  been  destroyed  by 
a  tumor.  In  hyperosmia,  it  is  always  necessary  to  treat  the  primary 
affection. 

Anosmia  is  much  more  freqtient  and  important.  In  exceptional  cases 
it  may  be  congenital  or  it  may  be  hereditary,  as  in  Cloquet's  case,  in 
which  the  filaments  of  the  olfactory  nerves  were  imperfectly  developed. 
Temporary  anosmia  occurs  in  coryza,  in  which  the  swelling  of  the  nasal 
mucous  membrane  and  the  accumulation  of  mucus  abolish  the  perception 
of  olfactory  impressions,  or  as  in  facial  paralysis,  in  which  the  applica- 
tion of  the  alfe  nasi  against  the  septum  of  the  nasal  fossa?  presents  an 
obstacle  to  the  penetration  of  air  charged  with  odoriferous  particles. 
Anosmia  is  also  produced  in  tumors  at  the  base  of  the  brain  {vide  p,  lO'-?), 
in  abscess  of  the  pituitary  gland  (Oppert),  rarely  in  syphilitic  thickening 
of  the  periosteum  and  mucous  membrane  (in  Romberg's  patient,  mercu> 


188  CLINICAL   TREATISE    ON 

rial  treatment  caused  the  disappearance  of  the  affection);  finally,  it  occurs 
in  hysteria,  in  which  disease  it  is  almost  always  accompanied  by  trigeminal 
anesthesia.  Partial  or  total  abolition  of  the  sense  of  smell  may  also  result 
from  chronic  rhinitis,  from  peripheral  lesions  (blow  upon  the  face  and  nose), 
or  from  the  prolonged  use  of  irritating  injections.  It  is  also  sometimes 
observed  in  the  course  of  typhoid  fever  and  meningitis,  and  the  loss  of 
smell  is  then  usually  spontaneously  restored.  Anaesthesia  of  the  first  pair 
may  be  combined  with  that  of  the  trigeminus  (as  in  hysterical  or  certain 
insane  patients),  and  the  mucous  membrane  then  loses  its  reflex  excitability. 
At  other  times,  the  anosmia  is  simple,  and  the  nasal  fossil  preserve  their 
normal  sensibility  despite  the  loss  of  smell.  In  a  case  of  this  kind  re- 
ported by  Pressat,  the  olfactory  nerves  and  the  foramina  of  the  cribriform 
plate  oi  the  ethmoid  bone  were  wanting,  but  the  orifices  intended  for  the 
ethmoid  nerves  were  preserved.  In  the  diseases  to  which  we  have  just  re- 
ferred, the  return  of  olfactory  perceptions  follows  general  tonic  treatment. 
In  the  anosmia  due  to  chronic  rheumatism,  traumatism,  or  hysteria,  benefit 
is  derived  from  faradization  of  the  nasal  mucous  membrane  (Duchenne, 
Beard  and  Rockwell).  In  the  other  cases,  it  is  almost  hopeless  to  expect 
any  improvement. 

b.  Diseases  of  the  Ojytic  Nerve. 

The  sensations  of  light  and  color,  and  the  illusions  produced  by  an 
abnormal  irritation  of  the  optic  nerve,  are  regarded  as  evidences  of  hy- 
peresthesia. The  latter  may  follow  a  direct  or  indirect  irritation  of  the 
optic  nerves  in  their  central  course. 

Congestive  conditions  of  the  brain,  the  development  of  cerebral  tu- 
mors, of  certain  mental  diseases  (hypochondria,  ecstasy),  hysteria,  chorea 
magna,  chronic  alcoholism  and  narcotism,  and  the  inhalation  of  toxic 
gases,  may  also  act  as  causes  of  optic  hyperesthesia.  Among  the  local 
causes,  we  may  mention  diseases  and  atrophy  of  the  optic  nerves  at  their 
periphery  (compression,  extravasation),  congestive  and  inflammatory  con- 
ditions of  the  retina,  the  sudden  perception  of  a  bright  light,  and  applica- 
tion to  delicate  work.  Hyperesthesia  of  the  optic  nerves  usually  follows 
a  chronic  course,  and  may  constitute  a  threatening  symptom,  especially 
in  central  affections,  in  which  it  is  very  frequently  the  forerunner  of  op- 
tic anaesthesia.  The  treatment  consists  of  the  application  of  leeches  to 
the  mastoid  processes,  of  cold  compresses  to  the  head,  cool  half-baths, 
stimulating  enemata,  tartar  emetic  in  divided  doses,  prolonged  rest  for 
the  eyes,  and  a  trip  to  the  country.  These  measures  sometimes  prove 
successful  at  the  onset  of  the  affection. 

Anesthesia  of  the  optic  nerve  is  called  amblyopia  or  amaurosis,  ac- 
cording as  the  visual  faculty  is  partially  or  completely  lost. 

Among  the  central  alterations  of  the  chiasm  or  optic  nerves,  we  must 
especially  refer  to  the  connective  tissue  thickenings  of  the  sheath  of  the 
optic  nerve,  and  to  optic  neuritis  and  its  sequences  {vide  p.  101).  In  ad- 
dition, more  or  less  advanced  atrophy  of  the  nerve,  changes  in  the  neuro- 
glia, an  abundant  formation  of  connective  tissue  in  the  interior  of  the  bun- 
dles, frequent  increase  of  the  cellular  elements,  and  development  of  gran- 
ular cells  and  amyloid  corpuscles,  are  also  found  (as  Virchow  and  Leber 
have  shown).  In  a  case  of  paralytic  dementia  with  unilateral  amaurosis, 
Meynert  found  the  external  geniculate  body  on  the  same  side,  and  the  in- 
ternal geniculate  body  on  the  opposite  side,  atrophied  and  sclerosed. 

The  diagnosis  is  conürmed  by  the  ophthalmoscopic  examination;  the 


DISEASES    OP   THE    NEEVOUS    SYSTEM.  189 

diminution  or  complete  abolition  of  the  movements  of  the  pupils  is  due 
to  the  absence  of  retinal  reflexes.  As  Tuerck  first  discovered,  pressure 
upon  the  cervical  vertebrte  or  mastoid  processes  in  optic  anaesthesia,  may 
have  a  momentary  favorable  or  unfavorable  influence  upon  the  visual  fac- 
ulty (by  reflex  action  through  the  trigeminal  nerve).  The  central  causes 
of  optic  anaesthesia  include:  neuroretinitis  following  cerebral  tumors, 
softening,  haemorrhages,  dropsy  of  the  ventricles,  optic  atrophy  in  ataxia, 
hysterical  cerebral  disorders,  malarial  cachexia,  Bright's  disease,  lead  pois- 
oning, syphilis.  In  the  latter  case,  the  disease  assumes  the  ordinary  ap- 
pearances of  cerebral  amaurosis  (atrophy  of  the  optic  nerves),  while  in 
ocular  syphilis  the  ophthalmoscope  reveals  the  symptoms  of  retinitis  or 
retino-choroiditis  (Sichel).  The  affection  is  of  peripheral  origin  in  trau- 
matism of  the  eyeball,  inflammation  and  haemorrhage  of  the  retina  and 
adjacent  parts,  retinal  tumors,  glaucomatous  compression,  tumors  of  the 
base  of  the  brain,  or  thickening  of  the  meninges  extending  to  the  chiasm. 
The  course  of  the  disease  is  usually  chronic  and  its  prognosis  is  almost 
always  unfavorable.  The  malarial,  hysterical,  saturnine,  syphilitic,  and 
haemorrhagic  forms  may  recover  after  appropriate  treatment. 

Before  the  discovery  of  the  ophthalmoscope,  strj-chnia  had  been  em- 
ployed in  atrophy  of  the  optic  nerves,  and  Nagel,  "VVoinow,  Hippel,  etc., 
have  again  advocated  its  employment  more  recently  (under  the  form  of 
hypodermic  injections).  But  further  observations,  to  which  I  may  add 
my  personal  experience,  have  not  confirmed  the  eflScacy  of  this  remedy. 
Santonine  has  been  recently  used  (Schoen),  but  we  do  not  know  as  yet 
"whether  better  results  are  to  be  expected  from  this  drug. 


c.  Neuroses  of  the  Acoustic  Nerve.  .  ■ 

Acoustic  neuroses,  which  are  naturally  more  obscure  and  much  more 
inaccessible  to  our  investigations  than  those  of  the  optic  nerve,  have  had 
considerable  light  thrown  upon  them  by  new  means  of  investigation  and 
especially  by  Brenner's  galvanic  method.  When  the  acoustic  nerve  is 
healthy,  if  one  of  the  poles  is  applied  to  the  previously  moistened  audi- 
tory meatus  or  to  the  tragus  (Erb),  and  the  other  pole  to  the  neck  or 
inner  side  of  the  arm,  and  the  intensity  of  the  current  be  regulated  by 
means  of  the  rheostat,  the  nerve  will  respond  to  the  galvanic  exploration 
with  the  normal  formula  of  reaction  viz. :  at  the  closure  of  the  cathode 
(KaF),  during  the  permanent  action  of  the  cathode  (KaD),  and  at  the 
opening  of  the  anode  (AO). 

Modifications  of  the  normal  reactions  will  be  observed,  however,  if  the 
acoustic  nerve  manifests  symptoms  of  irritation  or  depression. 

Acoustic  hyperaesthesia  may  be  of  central  origin,  as  in  chronic  cepha- 
lalgia, cerebral  hyperaemia,  irritative  conditions  of  the  brain  and  cord, 
hysteria,  insanity  (most  frequently  with  hallucinations  of  hearing),  etc. 
The  peripheral  causes  include  an  exaggerated  tension  of  the  muscles  and 
bones  of  the  ear,  with  secondary  compression  of  the  labyrinth.  Accord- 
ing to  Lucae's  recent  experiments  (Berl.  Klin.  Wschr.,  1874),  the  tensor 
tympani  muscle  presides  over  the  accommodation  for  musical  tones,  and 
the  stapedius  over  the  accommodation  for  shriller  and  non-musical  audi- 
tory sensations.  When  the  stapedius  is  paralyzed,  we  observe  an  abnor- 
mal acuteness  of  hearing  for  tones  and  noises,  i.e.  hypersesthesia.  This 
symptom  is  also  observed  at  times  in  facial  paralysis. 

Simple  acoustic  hypersesthesia,  following  disorders  in  conductibility 


190  CLINICAL    TREATISE    ON 

and  intracranial  lesions  of  the  acoustic  nerves,  or  combined  with  pa- 
ralysis of  the  ocular  muscles,  mydriasis,  etc.,  is  manifested,  according  to 
Brenner,  by  abnormal  excitability  of  hearing  to  weak  currents,  and  by 
much  greater  intensity  and  duration  of  auditory  sensations  (intense  ring- 
ing produced  by  closure  of  the  cathode  and  persisting  until  opening). 
These  reactions  may  be  formulated  as  follows: 

KaF  (loud  ringing).  AF  (no  reaction), 

KaD  (continuous  ringing).  AD  (  "         "       ). 

KaO  (no  reaction).  AO  (ringing  becomes  weaker). 

When  the  affection  is  more  pronounced,  the  hyperfesthesia  is  accom- 
panied by  qualitative  changes  in  the  reactions  in  question.  We  most 
frequently  observe,  in  addition  to  perverted  auditory  sensations,  an  ab- 
normal reaction  (only  in  the  affected  ear)  at  the  closure  of  the  cathode, 
during  continuous  action  at  the  anode  (AD),  and  more  rarely  at  the 
opening  of  the  cathode.     The  following  are  the  pathological  reactions: 

KaF  (increased  ringing).  AF  (loud'hissing). 

KaD  (continuous  ringing).  AD  (continuous  hissing). 

KaO  (hissing).  AO  (ringing  becomes  weaker). 

When  the  morbid  excitability  of  audition,  combined  with  simple  hy- 
perassthesia,  has  existed  for  a  long  time,  the  normal  reactions  grow 
weaker  and  weaker,  until  finally  only  the  abnormal  reactions  persist. 
According  to  Brenner,  the  reverse  of  the  phenomena  produced  in  simple 
hyper^esthesia  (reversal  of  the  reactions)  then  occur,  and  the  reactions 
observed  in  the  diseased  ear  may  be  expressed  as  follows  : 

KaF  (no  reaction).  AF  (ringing  loud). 

KaD  (  "         "      ).  AD  (ringing  continuous). 

KaO  (ringing  grows  weaker).  AO  (no  reaction). 

According  to  Brenner,  there  is  a  peculiar  form  of  exaggerated  audi- 
tory irritability,  consisting  of  hyperfesthesia  with  an  inverse  formula  to 
that  of  the  non-irritated  ear  in  old  and  severe  auditory  affections.  This 
condition  is  characterized  by  the  remarkable  fact,  that  upon  applying  the 
current  to  one  ear,  there  is  a  reaction  not  only  on  the  part  of  the  audi- 
tory nerve  of  this  side,  but  also  on  that  of  the  opposite  side. 

Galvanized  Ear.  Non-Qalvanked  Ear. 

KaF  (ringing).  (No  reaction). 

KaD  (ringing  con tinuotis).  (  "         '*      ). 

KaO  (no  reaction).  (Ringing  grows  weaker). 

AF     (  "         "      ).  (Ringing  loud). 

AD     ("         "      ).  (Ringing  grows  weaker). 

AO     (ringing  grows  weaker).  (No  reaction). 

Finally,  the  abnormal  excitability  of  the  acoustic  nerve  may  disap- 
pear although  the  reversal  of  the  formula  persists,  and  there  is  then  a 
modification  of  the  reactions  without  coexisting  hyperaesthesia.  Accord- 
ing to  Brenner,  we  may  also  observe  modifications  of  the  formula  with- 
out co-existing  hypersesthesia  (as  in  facial  paralysis). 

The  galvanic  treatment  of  acoustic  hyperaesthesia  has  met  with  a 
certain  amount  of  success.  This  is  especially  true  of  the  nervous  ring- 
ing in  the  ears  which,  according  to  Brenner,  diminishes  at  the  closure  of 


DISEASES    OF   THE   NEEVOUS    SYSTEM.  191 

the  anode  and  during  the  continuous  action  at  the  anode,  while,  on  the 
other  hand,  it  is  increased  by  opening  of  the  anode  and  closing  of  the 
cathode.  It  is  also  necessary,  in  order  to  avoid  any  persistent  cause  of 
irritation,  to  employ  very  gentle  currents  at  the  opening  and  closing  or 
the  circuit.  In  hyperaesthesia  with  an  inverse  formula  in  the  non-irri- 
tated ear  and  subjective  acoustic  sensations,  it  is  necessary,  according  to 
Brenner,  to  apply  the  anode,  divided  into  two  branches,  to  both  ears. 
Benedikt  recommends  the  employment  of  alternate  currents  (modification 
of  the  excitability  by  reversing  the  direction  of  the  current)  in  tinnitus 
aurium.  In  some  cases,  I  have  seen  the  symptoms  improve  after  galvani- 
zation, but  sooner  or  later  relapses  usually  occur.  In  these  cases,  good 
effects  are  sometimes  obtained  from  a  prolonged  stay  in  an  Alpine  region 
or  at  the  sea-shore. 

Anffisthesia  of  the  acoustic  nerve  or  torpor  (reactions  feeble  or  com- 
pletely absent  at  closure  of  the  cathode,  during  constant  action  of  the 
cathode,  opening  of  the  anode  or  reversal  of  the  current,  Brenner)  is  al- 
most always  accompanied  by  severe  and  persistent  disorders  of  the  fac- 
ulty of  audition,  and  is  caused  by  disturbances  of  conductibility  in  the 
central  or  peripheral  fibres  of  the  acoustic  nerve.  Independently  of  the 
poorly  understood  changes  which  the  acoustic  nucleus  may  undergo  in 
medullary  processes,  and  of  certain  localized  affections  in  the  mesocepha- 
lon,  posterior  regions  and  cerebellum,  we  must  also  take  into  considera- 
tion neoplasms  at  the  base  of  the  brain,  increase  of  intra-cranial  pressure 
(on  account  of  the  communications,  demonstrated  by  E.  Weber,  between 
the  arachnoid  space  and  the  labyrinth),  organic  affections  of  the  laby- 
rinth itself,  and  probably  also  certain  forms  of  neuritis  of  the  acoustic 
nerve  which  have  been  hitherto  but  little  studied.  In  two  cases  of  ner- 
vous deafness,  Hiebrich  has  recently  noted  (Arch,  f,  Ps)ch.,  V.  Bd.,  1874) 
the  integrity  of  the  labyrinth  and  of  the  cavity  of  the  tympanum,  and 
traced  an  amyloid  degeneration  of  the  acoustic  nerve  into  the  medulla 
oblongata.  The  deafness  observed  in  ataxia,  hysteria,  typhoid  fever  and 
the  acute  exanthemata,  is  due  either  to  profound  disturbances  or,  in 
curable  forms,  to  slight  changes  in  the  meninges.  Deaf-nndhm  is  caused 
by  malformation  of  the  middle  and  internal  ear,  either  congenital  or 
acquired  during  childhood  after  cerebral  diseases. 

We  can  only  expect  slight  results  from  treatment.  Acoustic  hyperaes- 
thesia  is  sometimes  improved  by  galvanization  (Brenner),  strong  but  not 
painful  currents  being  employed,  and  the  current  being  alternated  from 
the  anode  to  the  cathode.  Duchenne,  Erdmann,  etc.,  have  obtained 
benefit  from  faradization  of  the  ear  in  nervous  deafness;  Duchenne  met 
with  similar  success  in  a  case  of  deaf-mutism. 


d.  Neuroses  of  the  Gustatory  Nerves. 

In  concluding  our  consideration  of  the  pathology  of  the  nerves  of 
special  sensibility,  we  shall  examine  the  most  striking  facts  in  the  nor- 
mal and  pathological  history  of  the  organs  of  taste,  although  the  nerves 
■which  are  distributed  to  these  organs  belong  in  reality  to  the  mixed 
nerves.  The  most  important  of  the  gustatory  nerves  of  the  tongue  is 
the  glosso-pharyngeal,  which  is  chiefly  distributed  to  the  posterior  third 
of  the  organ,  but  also  in  part  to  its  anterior  third,  by  means  of  a  filament 
discovered  by  Hirschfeld.  According  to  the  experiments  of  Stannius,  it 
presides  exclusively  over  the  sensation  of  bitterness  in  the  corresponding 


192  CLINICAL    TREATISE    ON 

parts  of  the  tongue.  The  other  gustatory  perceptions  are  determined 
by  nerve-fibres  of  different  orders.  These  consist  of  the  fibres  of  the 
chorda  tympani  and  lingual  nerves,  which  subserve  the  gustatory  func- 
tions of  the  anterior  region  of  the  tongue.  Section  or  lesion  of  the 
chorda  tympani  within  the  middle  ear  (Bernard,  Lussana,  Neumann) 
abolishes  gustation  in  the  anterior  third  of  the  tongue,  in  the  same  man- 
ner as  section  of  this  nerve  before  its  reunion  with  the  lingual  at  the  base 
of  the  brain.  In  man,  resection  of  the  lingual  nerve  deprives  the  ante- 
rior part  of  the  tongue  of  all  gustatory  function  (Busch,  Inzoni,  Vanzetti, 
etc.). 

According  to  Schiff's  experiments  (Molesch.  Unters.,  X.  Bd.,  and  II 
Morgagni,  1870),  the  fibres  of  the  chorda  tympani  leave  the  facial  nerve 
at  the  ganglion  geniculata,  unite  with  the  large  and  small  superficial 
petrosal  nerves,  pass  through  the  otic  and  spheno-palatine  ganglia  to 
the  trigeminus  and  reach  the  brain  in  the  second  branch  of  this  nerve. 
On  the  other  hand,  according  to  Lussana  (Arch,  de  Physiol.,  1869  and 
1872),  the  fibres  of  the  chorda  tympani  arrive  at  the  brain  with  the 
facial,  and  the  trunk  of  the  trigeminus  does  not  contain  any  gustatory 
fiibres.  The  pathological  data  tend  to  support  Schiff's  opinion.  In  tri- 
geminal paralysis  from  lesions  at  the  base  of  the  brain,  with  integrity  of 
the  facial,  taste  is  affected  in  the  anterior  half  of  the  tongue.  Erb  has 
collected  and  carefully  analyzed  the  observations  which  point  to  this  con- 
clusion (Arch.  f.  Klin.  Med.,  XV.  Bd.,  1874).  On  the  other  hand,  accord- 
ing to  the  results  of  the  autopsies  reported  by  Ziemssen,  Wachsmuth, 
etc.  (excluding  the  cases  complicated  with  lesions  of  the  fifth  pair),  it  is 
not  probable  that  the  trunk  of  the  facial,  at  the  base  of  the  brain,  con- 
tains the  gustatory  fibres  of  the  anterior  part  of  the  tongue.  In  certain 
cases  of  isolated  facial  paralysis,  an  alteration  or  loss  of  taste  is  observed 
in  the  corresponding  part  of  the  tongue,  a  phenomenon  which  is  due  to 
the  simultaneous  affection  of  the  fibres  of  the  chorda  tympani  contained 
in  the  facial  nerve. 

All  the  preceding  questions  must  be  cleared  up  by  physiology,  clinical 
observation,  and  pathological  anatomy.  It  now  remains  for  us  to  discuss 
the  interesting  phenomena  of  hyper^esthesia  and  anaesthesia  of  the  gusta- 
tory nerves.  Hyperassthesia  of  taste  (hy  pergeusia)  or  the  abnormally  exag- 
gerated excitability  of  the  gustatory  perceptions,  is  sometimes  observed 
in  marked  neuropathic  conditions,  such  as  hysteria  and  melancholia.  In 
order  to  obtain  a  scientific  conception  of  this  hyperesthesia  of  taste,  we 
must  take  into  consideration  Valentin's  experiments  (Lehrb.  d.  Physiol., 
II.  Bd.)  upon  the  minimum  conditions  of  gustatory  excitability,  and  also 
the  degrees  of  sensibility  recently  established  by  Keppler,  according  to  the 
different  concentration  of  the  solutions  employed.  I  have  recognized  for 
a  long  time  that  in  irritative  conditions  of  the  centres  in  very  nervous, 
antemic,  and  hysterical  individuals,  the  application  of  weak  ascending  gal- 
vanic currents  (especially  upon  closure  and  during  constant  action  of  the 
cathode)  to  the  cervical  or  upper  dorsal  vertebrae,  will  produce  a  gustatory 
sensation  of  electrical  origin.  The  current  may  exercise,  in  these  cases, 
an  exciting  action  upon  the  corresponding  centres. 

Anaesthesia  of  taste  (ageusia)  i$  observed  after  surgical  section  of  the 
lingual  nerve  in  neuralgias,  and  after  traumatic  or  intr^-cranial  paralysis 
of  the  trigeminus  (Hirschberg).  I  have  also  reported  cases  of  basilar 
tumors  (p.  102),  in  which,  in  addition  to  unilateral  anosmia,  abolition  of 
taste  was  observed  upon  the  left  half  of  the  tongue.  In  Boettcher's  obser- 
vation reported  in  the  sanie  chapter,  the  patient  complained  of  a  sensation 


DISEASES    OF   THE    NERVOUS    SYSTEM.  193 

of  burning  aad  bitterness  in  the  mouth,  and  upon  autopsy  a  tumor  was 
found  at  the  base  of  the  brain,  compressing  the  glosso-pharyngeal  and 
pneumogastric  nerves,  which  were  in  a  condition  of  fatty  degeneration. 
I;Oss  of  taste  has  also  been  noticed  in  atrophy  of  the  glosso-pharyngeal 
nerve  from  compression  by  tumors  situated  at  the  jugular  foramen.  But 
in  the  cases  reported  by  Longet  (in  his  Physiologie  nerveuse),  the  affection 
was  complicated  by  lesions  of  the  trigeminal,  pneumogastric,  and  spinal 
accessory  nerves.  Finally,  in  anaesthesia,  there  is  usually  an  incomplete 
or  complete  abolition  of  taste,  according  as  one  or  both  halves  of  the 
buccal  cavity  and  tongue  are  antesthetic.  As  a  rule,  we  usually  find,  at 
the  same  time,  anaesthesia  of  other  nerves  of  special  sense  (olfactory,  optic, 
acoustic)  and  of  the  skin,  mucous  membranes,  and  articulations. 

The  prognosis  of  anaesthesia  of  taste  depends  upon  the  nature  of  the 
primary  disease.  In  gustatory  disturbances  from  rheumatic  facial  paralysis 
recovery  occurs  spontaneously;  anaesthesiae  of  central  origin  (cerebral  or 
spinal)  present  an  unfavorable  prognosis,  but  it  is  more  favorable  in  hyster- 
ical ageusia.  We  do  not  as  yet  possess  sufficient  clinical  data  with  regard 
to  the  re-establishment  of  the  gustatory  functions  after  surgical  excision 
of  the  lingual  or  facial  nerves  to  aid  us  in  forming  a  prognosis.  In  hys- 
terical anaesthesia  of  taste  Duchenne  has  obtained  good  results  from  fara- 
dization of  the  tongue. 
Vol.  II.— 13 


I 


194  CLINICAL   TREATISE    ON 


CHAPTER  XLV. 

B. — Diseases  of  the  Motor  Cranial  Nerves  (Octjlae,  Facial,  and 
Hypoglossal  Nerves). 

a.  Diseases  of  the  Ocular  Muscles. 

The  symptoms  of  motor  irritation  on  the  part  of  the  ocular  muscles 
are  ahnost  exclusively  observed  in  cerebral  and  spinal  affections  attended 
with  convulsions  and  in  hysteria.  Contractures  of  the  ocular  muscles  may 
result  from  direct  irritation  originating  in  some  pathological  process,  or 
from  prolonged  paralysis  of  the  antagonists.  Spasm  of  the  muscular 
fibres  of  the  iris  are  secondary,  in  rare  cases,  to  irritative  conditions  of  the 
cerebro-spinal  system,  which  have  involved  the  cilio-spinal  centre  (further 
details  upon  this  point  will  be  found  in  preceding  chapters).  Clonic 
spasms  of  the  external  muscles  of  the  eye,  attended  either  with  simple 
oscillations  or  with  involuntary  rotatory  movements,  constitute  the  phe- 
nomenon known  as  nystagmus.  It  is  always  double  and  may  be  pro- 
duced by  central  causes  (meningitis,  hydrocephalus),  by  peripheral  causes, 
such  as  uterine  disease,  worms,  dental  caries,  or  by  a  disease  of  the  re- 
fracting media  of  the  eye  or  of  the  retina.  According  to  Adamueck's 
and  Ferrier's  experiments,  the  starting-point  of  nystagmus  is  situated  in 
the  anterior  tubercula  quadrigemina. 

The  prognosis  of  these  symptoms  depends  upon  the  intensity  of  the 
central  causes,  though,  as  a  rule,  it  is  not  favorable.  In  adopting  any 
plan  of  treatment,  we  must  endeavor  to  relieve  the  irritation  of  the  central 
nervous  system.  The  relatively  best  results  are  furnished  by  the  use  of 
atropine,  quinine,  bromide  of  potassium,  mild  hydrotherapeutic  measures, 
and  by  the  electrical  treatment  to  which  we  shall  refer  in  discussing 
paralysis  of  the  ocular  muscles. 

Paralysis  of  these  muscles  may  be  either  a  complication  or  an  initial 
symptom  of  central  affections,  or  may  result  from  peripheral  causes.  Pa- 
ralysis of  the  motor  oculi  communis  is  most  frequent  and  is  observed  under 
the  following  circumstances:  exposure,  syphilis  (affecting  the  nerve  in  its 
central  or  peripheral  portions),  orbital  tumors,  circumscribed  meningeal 
processes  at  the  base  of  the  skull,  tumors  of  the  cerebral  peduncles  (pa- 
ralysis of  the  oculo-motor  on  the  side  of  the  tumor,  with  a  tendency  to 
extension  to  the  nerve  on  the  opposite  side),  heemorrhages  and  softening 
of  the  cerebral  ganglia,  the  cerebral  peduncles  and  adjacent  parts,  ataxia 
(sometimes  with  simultaneous  paralysis  of  other  cranial  nerves),  finally, 
diphtheria,  and  aneurisms  of  the  carotid  (Lebert).  Paralysis  of  the  external 
motor  oculi,  either  single  or  double,  occurs  in  central  affections,  and  in 
rheumatism,  syphilis,  orbital  lesions,  traumatism  and  cerebral  tumors;  this 
also  holds  good  of  paralysis  of  the  patheticus. 

Ocular  paralysis  of  cerebral  origin  may  affect  the  muscles  partially  or 
in  their  totality,  exists  symmetrically  upon  both  sides,  or  extends  pro- 
gressively to  other  ocular  nerves.  These  paralyses  very  often  constitute 
(under  the  form  of  insufficiency  and  diplopia)   the  first  signs  of  chronic 


DISEASES    OF   THE   NERVOUS    SYSTEM.  195 

cerebral  affections  (tumors,  basilar  inflammations,  cerebral  aneurisms)  and 
their  true  character  is  then  recognized  by  the  following  conditions:  co- 
existence of  cephalalgia  and  vertigo,  early  appearance  of  neuro-retinitis 
(hypertemia  and  swelling),  more  or  less  circumscribed  or  general  convul- 
sive movements,  feeling  of  heaviness  in  the  limbs  (usually  of  the  hemi- 
plegic  type);  disturbance  of  speech,  disorders  of  the  intellectual  facul- 
ties; later,  symptoms  on  the  part  of  other  cranial  nerves;  paresis  or 
paralysis  of  the  limbs. 

Ocular  paralyses  of  spinal  origin  (frequent  prodromata  of  ataxia)  are 
accompanied  by  vague  neuralgias  in  the  branches  of  the  cervical  and 
brachial  plexuses,  and  in  the  sciatic  nerves;  they  are  complicated  by  ab- 
normal sensations  in  the  back,  knees,  or  soles  of  the  feet,  by  sexual 
irritability  (pollutions,  frequent  erections,  diminution  of  virile  power),  a 
tendency  to  fatigue,  sometimes  manifested  upon  rising  from  bed,  extreme 
sensitiveness  to  wind  and  moisture,  and  increase  of  the  galvanic  excita- 
bility of  the  nerve-trunks.  Ocular  paralyses  of  bulbar  origin  (motor 
oculi  communis  and  externus)  result  from  an  affection  of  the  correspond- 
ing nerve  nuclei  in  glosso-labio-pharyngeal  paralysis  and  ataxia,  and  are 
accompanied  by  other  characteristic  signs  of  these  affections.  Ocular 
paralyses  of  a  peripheral  nature  are  xisually  of  rheumatic  origin;  they 
develop  without  other  symptoms  of  a  central  affection,  and  chiefly  affect 
the  motor  oculi  communis  and  externus.  According  to  E.  H.  Weber's 
experiments,  the  ocular  region,  especially  at  the  inner  and  outer  angles, 
is  very  sensitive  to  heat  and  cold. 

The  diagnosis  presents  no  especial  difficulties  in  the  majority  of  ocu- 
lar paralyses.  In  complete  paralysis  of  the  motor  oculi  communis  the 
upper  lid  droops,  and  the  eyeball  is  only  moved  by  the  external  rectus 
and  superior  oblique  muscles.  External  strabismus  is  therefore  produced, 
and  the  eye  does  not  accompany  the  unaffected  one  in  its  movements; 
these  are  supplemented  by  the  movements  of  the  head.  The  pupil  is 
moderately  dilated  (paralysis  of  the  sphincter  of  the  iris),  and  the  eye  only 
accommodates  itself  for  a  single  visual  distance  (paralysis  of  the  tensor  of 
the  choroid).  In  isolated  paralysis  of  the  upper  branch,  ptosis  is  pro- 
duced, but  the  eye  preserves  its  lateral  movements.  In  paralysis  of  the 
inferior  branch,  there  is  no  ptosis,  but  external  strabismus  (paralysis  of 
the  internal  rectus)  and  pupillary  dilatation  occur.  The  rotatory  move- 
ments of  the  eye  and  accommodation  are  equally  disturbed. 

Paralysis  of  the  external  oculo-motor  is  characterized  b}--  internal 
strabismus,  diplopia  in  the  outer  part  of  the  field  of  vision,  and  preserva- 
tion of  the  other  movements  of  the  eye.  In  paralysis  of  the  patheticus, 
the  position  of  the  eye  is  but  little  modified,  but  sight  is  disturbed  by  the 
formation  of  two  images,  which  are  situated  obliquely  above  one  another. 
When  the  head  is  inclined  to  the  sound  side,  the  two  images  become  con- 
fused; they  grow  clearer,  on  the  other  hand,  when  the  head  is  inclined  to 
the  paralyzed  side.  In  the  beginning,  the  head  is  carried  forwards  (in 
order  to  command  the  tipper  part  of  the  field  of  vision),  but  later  the 
head  is  turned  around  the  vertical  axis  (towards  the  sound  side)  in  order 
to  place  the  objects  in  the  two  symmetrical  halves  of  the  visual  field. 
For  the  subtle  signs  of  these  affections,  especially  in  complicated  para- 
lyses, we  refer  to  the  investigations  of  Graefe  (Arch.,  I.  Bd.,  1854)  and  to 
the  clinical  labors  of  Arlt  (Krankh.  d.  Auges,  III.  Bd.,  1856). 

The  consideration  of  ocular  paralyses  is  especially  interesting  witli  reference  to  the 
clinical  study  of  paralysis  in  general.     The  most  significant  fact  in  the  delicate  and 


196  CLIISICAL   TREATISE    ON 

harmonious  play  of  the  ocular  muscles,  is  that  the  various  forms  and  degrees  of 
functional  disturbances  are  due  to  different  causes.  Diplopia  and  strabismus  may  re- 
sult from  an  inequality  in  the  energy  of  the  ocular  muscles  on  both  sides.  One  of 
these  muscles  is  more  readily  fatigued  in  the  various  movements  of  one  or  both  eyes, 
furnishes  less  force  than  its  associate,  and  cannot  maintain,  as  in  the  normal  condition, 
the  maximum  point  in  its  course,  although  the  absolute  amount  of  its  mobility  may 
not  be  compromised.  This  unilateral  enfeeblement  of  the  muscular  energy  may  be 
merely  temporary,  as  in  slight  cerebral  irritations ;  it  may  also  present  alternations, 
corresponding  to  the  modifications  in  the  cerebral  condition.  It  is  especially  mani- 
fested in  accommodation,  and  in  very  marked  convergence  or  divergence  of  the  visual 
axes.  A  slight  diminution  in  the  tonicity  of  an  ocular  muscle  may  not  be  revealed 
by  any  pathological  signs.  If  its  energy  diminishes  markedly,  we  will  perceive,  in. 
excursions  of  the  eye,  an  abnormal  position  of  the  globe  and  the  action  of  the  an- 
tagonists then  reveals  a  want  of  harmony  in  a  certain  direction.  When  the  paresis  is 
even  more  marked,  the  antagonist  will  maintain  the  upper  hand  even  in  a  condition  of 
repose,  and  the  eye  sometimes  assumes  persistent  pathognomonic  positions,  which 
may  terminate,  in  certain  cases,  in  true  paralysis.  Finally,  there  are  certain  disorders 
in  the  associated  movements  of  both  eyes,  which,  in  binocular  vision,  cause  secondary 
functional  affections  on  the  part  of  the  muscles. 

Among  the  anatomical  lesions  in  disorders  of  the  ocular  movements, 
alterations  in  the  muscular  substance  are  much  more  rarely  observed  than 
changes  in  the  nerve-fibres  and  in  their  central  origins.  In  fact,  certain 
slight  and  initial  disorders  of  innervation  (first  period  of  cerebral  dis- 
orders or  ataxia)  are  manifested  by  diplopia  and  strabismus,  before  the 
other  parts  of  the  muscular  system  have  become  affected.  These  phe- 
nomena frequently  present  a  spontaneous  retrogression,  but  may  then 
return  with  symptoms  of  sensory  irritation  (parresthesia,  neuralgia),  a  fact 
"which  proves  that  morbid  processes  are  slowly  developing  in  the  nerve- 
centres.  For  the  same  reason,  tenotomy,  which  is  sometimes  performed 
by  oculists  in  diplopia  of  this  character,  only  furnishes  incomplete  re- 
sults. The  operation  may  diminish  but  will  not  cause  the  entire  disappear- 
ance of  the  difference  in  the  height  of  both  images,  since  the  latter  vary 
according  to  the  visual  angle,  and  according  to  the  side  to  which  the 
movements  are  directed.  In  correcting  the  error  in  one  direction,  an  ag- 
gravation of  the  symptom  in  the  opposite  direction  is  produced,  and  we 
cannot  entirely  compensate  those  disorders  which  are  produced  by  in- 
sufficient innervation. 

The  2^^ognosis  of  ocular  paralyses  is  more  or  less  unfavorable  accord- 
ing to  the  nature  and  intensity  of  the  affection  which  gives  rise  to  them. 
In  severe  cerebral  diseases  (tumor,  softening)  there  is  no  hope  of  im- 
provement; in  circumscribed  meningeal  processes  and  in  hasmorrhages 
into  the  cerebral  peduncle,  the  paralysis  (of  the  motor  oculi  communis) 
may  retrocede.  The  ocular  paralysis  in  ataxia  often  disappears  spon- 
taneously during  the  first  periods,  though  we  cannot,  therefore,  draw  any 
favorable  conclusions  with  regard  to  the  progress  of  the  central  affec- 
tion. Peripheral  paralysis  usually  presents  a  favorable  prognosis,  but  the 
chronic  forms  (with  atrophy  and  fatty  degeneration  of  the  muscles)  are 
almost  always  incurable. 

The  treatment  of  ocular  paralyses  should  be  begun  as  soon  as  possible. 
Electrotherapeutics  renders  relatively  the  best  services.  On  account  of 
the  deep  situation  of  the  ocular  muscles  and  their  slight  motor  irritability, 
faradization  is  less  indicated  than  galvanization.  According  to  Benedikt, 
an  application  of  half  a  minute's  duration  should  be  made  daily,  from 
five  to  fifteen  Siemens'  elements  being  employed,  according  to  the  sensi- 
bility of  the  skin.  The  anode  is  placed  upon  the  forehead.  The  cathode, 
in  paralysis  of  the  eyelid,  internal  rectus  and  superior  oblique  muscles,  is 


DISEASES    OF    THE    NERVOUS    SYSTEM.  197 

placed  in  the  neighborhood  of  the  inner  angle  of  the  eye;  in  paralysis  of 
the  superior  rectus,  upon  the  upper  border  of  the  orbit;  in  paralysis  of 
the  external  rectus,  upon  the  malar  bone.  In  mydriasis,  the  anode  is  ap- 
plied over  the  closed  lid.  Eulenburg  and  myself  have  also  applied  the 
constant  current  directly  to  the  sclerotic,  in  cases  of  ocular  paralyses. 
For  this  purpose,  very  weak  currents  are  employed  (one  to  two  Siemens' 
elements)  with  a  curved  electrode  as  thick  as  a  knitting-needle,  which  is 
applied  to  the  sclerotic  for  one  or  two  minutes,  as  near  as  possible  to  the 
insertions  of  the  muscles.  Faradic  currents  are  apt  to  produce  a  local  hy- 
persemia,  which,  however,  soon  disappears. 

b.  Diseases  of  the  Facial  Nerve. 

1.    SPASMS    OF    THE    MUSCLES    OF    THE    FACE. 

We  frequently  observe  an  irritable  condition  of  the  facial  nerve  which 
gives  rise  to  mimic  spasm  of  the  face  or  convulsive  tic,  and  which  may 
result  from  an  irritation  of  the  nerve  in  the  brain,  from  reflex  irritation, 
or  from  causes  which  act  upon  the  peripheral  course  of  the  nerve.  In 
rare  cases,  the  affection  is  hereditary  in  its  nature.  I  am  acquainted  with 
a  family  in  which  the  mother,  son,  daughter,  and  two  other  relatives  on  the 
maternal  side,  are  affected  with  more  or  less  extensive  facial  spasm.  In  ex- 
citement, mental  diseases,  affections  of  the  brain  and  its  envelopes,  and  in 
general  neuroses  (epilepsy,  eclampsia,  tetanus,  chorea,  hysteria),  tonic  or 
clonic  spasms  which  are  of  central  origin,  occur  in  the  face;  to  them  we 
have  referred,  in  discussing  these  various  diseases.  In  the  following 
remarks,  we  shall  only  consider  the  facial  spasm  due  to  reflex  action  or  to 
direct  irritation  along  the  course  of  the  nerve. 

Cases  of  this  character  are  due  to  exposure,  wounds  of  the  face,  and 
compression  of  the  peripheral  nerve  filaments.  Thus,  in  Schuh's  patient, 
the  facial  spasm  (with  prosopalgia)  was  caused  by  a  cholesteatoma  at  the 
base  of  the  brain;  in  Romberg's  case,  by  an  inflammation  of  the  lymphatic 
glands  along  the  trunk  of  the  facial  nerve;  in  Oppolzer's  patient,  by  caries 
of  the  temporal  bone.  Remak  and  myself  have  observed  several  instances 
of  peripheral  facial  paralysis  following  an  otitis  (probably  with  destruction 
of  the  Fallopian  canal),  in  which  spasms  developed  in  the  facial  muscles. 

Facial  spasms  are  much  more  frequently  of  a  reflex  nature,  from  irri- 
tation of  the  trigeminus,  dental  caries,  periostitis,  irritation,  or  inflamma- 
tion of  the  eyeball,  the  lids,  and  conjunctiva.  The  spasm  described  by 
Graefe,  with  painful  points  upon  pressure  along  the  peripheral  course  of 
the  sensory  branches,  may  be  due  to  swelling  of  the  nerves  in  the  interior 
of  their  osseous  canals.  We  may  here  mention  an  observation  made  by 
Remak  in  a  case  of  cervico-brachial  neuritis  (with  nodosities  along  the 
course  of  the  nerves),  of  a  spasm  starting  from  the  hand  and  arm,  and 
extending  to  the  neck  and  face  on  the  same  side.  Finally,  we  may  refer 
to  the  reflex  facial  spasms  which  are  secondary  to  intestinal  irritation 
(worms)  and  to  diseases  of  the  female  sexual  organs. 

Facial  spasms  may  be  tonic;  the  rigidity  of  the  features,  the  furrow- 
ing of  the  face,  and  the  muscular  tension  observed  in  tetanus,  after 
exposure,  in  facial  paralysis,  or  too  intense  faradization,  are  of  this  char- 
acter; or  they  may  be  clonic,  with  grimacing  movements  of  the  forehead, 
and  eyebrows,  and  contractions  in  the  lids,  lips,  nose,  cheeks,  tongue,  and 
muscles  of  the  neck,  causing  a  profound  change  in  the  expression  of  the 
features  and  the  position  of  the  head.     The  contractions  are  then  sepa- 


198  CLINICAL    TREATISE    ON 

rated  by  intervals  of  relaxation,  and  often  reappear  in  the  muscles  accord- 
ing to  a  certain  rhythm,  although  the  patients  do  not  complain  of  fa- 
tigue. Excitement  and  effort  favor  the  appearance  of  these  convulsive 
movements  and  increase  their  intensity. 

From  a  diagnostic  point  of  view,  vre  must,  above  all,  eliminate  the  fa- 
cial spasms  dependent  on  central  affections;  the  latter  are  usually  accom- 
panied by  convulsions  of  the  limbs,  and  by  disorders  of  the  mental  facul- 
ties and  special  senses.  Careful  observation  will  determine  whether  the 
facial  nerve  is  exposed  to  a  direct  irritation  along  some  point  of  its  course, 
or  whether  the  spasm  is  produced  by  reflex  means,  in  which  event  we  will 
sometimes  find  an  irritation  of  the  sensory  nerves  in  the  neighborhood  of 
the  eye,  in  the  branches  of  the  trigeminus,  or  in  the  buccal  cavity. 

The  prognosis  is  not  unfavorable  in  cases  which  are  recent  or  of  slight 
duration,  in  circumscribed  spasms,  or  in  those  due  to  rheumatic  influen- 
ces. But  in  chronic,  severe  and  extensive  forms  of  convulsive  tic,  which 
have  extended  to  the  motor  portions  of  the  trigeminus  and  spinal  acces- 
sory, positive  improvement  and,  still  less,  recovery  are  rarely  obtained. 

The  treatment  of  facial  spasm  varies  according  to  its  causation.  The 
cases  which  are  due  to  exposure,  recover  from  the  use  of  active  cutaneous 
revulsives,  vapor-baths,  facial  douches  (the  water  at  first  of  a  medium 
temperature  and  then  gradually  cooled).  Moist  packs  continued  until  the 
return  of  warmth,  followed  by  affusions  to  the  head  in  a  cool  half-bath, 
are  also  useful  in  these,  and  even  in  somewhat  older  and  more  extensive 
cases,  in  order  to  diminish  the  reflex  excitability.  The  same  end  can  be  ob- 
tained by  subcutaneous  injections  of  atropine  and  morphine,  and  by  large 
doses  of  bromide  of  potassium.  In  one  rebellious  case,  Sander  obtained 
complete  relief  by  the  hypodermic  administration  of  strychnine;  Gualla  ob- 
tained similar  results  from  the  use  of  curare.  In  two  cases  of  facial  spasms 
with  intense  blepharospasm,  Romberg  procured  permanent  recovery  by 
section  of  the  supra-orbital  nerve.  Graefe  found  good  results  from  tenot- 
omy in  cases  of  irritation  of  the  eye  and  its  annexes.  Dieffenbach  cured 
a  patient  by  a  subcutaneous  section  of  the  muscles  affected  with  spasm. 

Remak  claims  to  have  cured  facial  spasm  on  several  occasions  by  gal- 
vanization of  the  sympathetic.  Lately',  Frommhold  and  Erb  have  com- 
pletely relieved  this  affection  by  means  of  induction  currents  which  were 
gradually  made  stronger  and  stronger  (application  of  the  positive  pole 
to  the  neck  and  of  the  negative  pole  to  the  affected  muscles). 

2.    PARALYSIS    OF   THE   MUSCLES   OF   THE   FACE. 

After  having  discussed,  in  previous  sections,  the  varieties  of  facial 
parah^sis  due  to  lesions  of  the  facial  nucleus  and  of  the  nerve  during  its 
course  at  the  base  or  in  the  interior  of  the  brain,  we  shall  consider  the 
paralyses  of  the  seventh  pair  which  are  secondary  to  processes  acting 
upon  the  peripheral  terminations.  According  to  the  nature  and  intensity 
of  the  cause,  the  symptomatology  of  facial  paralysis  presents  important  dif- 
ferences, the  distinctions  between  which  were  first  pointed  out  by  Charles 
Bell  and  then  by  Romberg.  Continual  progress  in  this  direction  is  being 
made  at  the  present  time  through  the  aid  furnished  by  experimentation. 

In  order  to  facilitate  matters,  we  shall  classify  peripheral  facial  paraly- 
sis according  to  its  causes,  and  shall  divide  it  into  six  groups,  furnish- 
ing examples  of  each  class  (in  the  Wien.  Med,  Presse,  18C8,  I  have  given 
a  detailed  account  of  the  various  forms  of  facial  paralysis,  with  twenty 
personal  observations). 


DISEASES    OF   THE    NEEVOUS    SYSTEM.  199 

1.  We  shall  first  refer  to  facial  paralysis  from  diseases  at  the  base  of 
the  brain.  In  basilar  tumors  and  in  compression  of  the  roots  of  the 
facial  nerve  at  the  pons  varolii  the  nerve  is  affected  with  paralysis  in  the 
first  portion  of  its  peripheral  course.  In  these  intra-cranial  forms  of  facial 
paralyses  the  paralysis  is  total,  and  its  peripheral  origin  is  shown  by  the 
different  reactions  to  the  galvanic  and  faradic  currents,  to  which  I  have 
previously  referred.  Observations  of  this  kind  have  been  reported  in  de- 
tail upon  pages  118  and  126,  127. 

2.  In  facial  paralysis  from  suppuration  or  haemorrhage  in  the  interior 
of  the  auditory  apparatus,  a  diminution  or  abolition  of  electro-muscular 
contractility,  and  of  the  galvanic  and  faradic  excitability  of  the  nerve,  is 
observed;  these  symptoms  vary  according  to  the  intensity  and  chronicity 
of  the  facial  lesion.  In  an  observation  by  Erb  (tubercular  caries  of  the 
temporal  bone,  paralysis  of  the  left  facial  with  partial  abolition  of  faradic 
excitability),  the  facial  nerve  floated  free  in  a  cavity  filled  with  pus,  and 
was  surrounded  by  a  mass  which  was  intimately  adherent  to  the  neurilemma 
(connective  tissue  with  scattered  round  cells).  Fibrillary  connective  tissue 
with  oval  nuclei  was  also  found  between  the  nerve-fibres  and,  in  a  portion 
of  the  fibres,  there  was  destruction  of  the  myeline  and  production  of  fat 
granules.  Some  branches  of  the  facial  and  of  the  pes  anserinus  presented 
a  similar  degeneration.  In  the  muscles  there  was  increase  of  the  inter- 
fibrillary  connective  tissue,  formation  of  nuclei  and  atrophy  of  the  mus- 
cular fibres,  a  portion  of  which  were  in  a  condition  of  waxy  degenera- 
tion. 

In  the  chronic  cases  which  I  have  observed  in  adults,  I  have  always  ob- 
tained some  improvement.  One  case  of  acute  facial  paralysis,  following 
otitis,  recovered  completely  by  the  use  of  weak  astringent  injections  and 
iodide  of  potassium.  In  children,  I  have  seen  the  facial  hemiplegia  soon 
disappear,  after  the  auricular  affection  (intense  hyperjemia  or  transuda- 
tion into  the  Fallopian  aqueduct)  has  improved.  The  fibres  of  the  facial  are 
affected  in  otitis  to  a  variable  degree.  I  have  published  one  case  in  which 
the  paralysis,  which  had  lasted  for  twenty-two  years,  followed  a  purulent 
catarrh  of  the  middle  ear,  with  perforation  of  the  tympanum,  from  which 
the  patient  had  suffered  during  childhood  (the  centre  of  the  tympanum 
was  occupied  by  a  thick  cicatrix,  Politzer).  The  faradic  and  galvanic  ex- 
citability were  abolished  in  the  upper  muscles  of  the  face,  but  were  still 
present,  to  a  slight  extent,  in  the  lower  muscles.  The  trunk  of  the  nerve 
was  completely  insensible  to  galvanization;  when  the  temporal  region 
was  touched,  contractions  of  the  lips  were  produced.  Galvanic  treatment 
merely  improved  the  play  of  the  features. 

Facial  paralysis  from  haemorrhage  into  the  Fallopian  aqueduct  (usually 
after  a  blow  upon  the  ear)  is  accompanied  at  the  onset  by  loss  of  con- 
sciousness, a  sanguineous  discharge  from  the  ear,  followed  by  enfeeble- 
ment  of  hearing  and  often  by  deviation  of  the  uvula  and  palate  towards 
the  paralyzed  side.  In  lesions  of  the  petrosus  superficialis  major  there  is. 
obliquity  of  the  uvula  and  pillars  of  the  palate  (which  also  happens  in 
other  facial  paralyses) ;  but  simple  deviation  of  the  uvula,  especially  when 
the  latter  is  very  long  and  touches  the  base  of  the  tongue,  is  very  often 
observed  in  a  condition  of  health. 

3.  Rheumatic  facial  paralyses  are  the  most  numerous  and  extended 
of  all  varieties  due  to  external  causes  (the  ocular  branch  is  almost  always 
affected  at  the  same  time).  According  to  E.  H.  Weber's  experiments, 
the  cheeks,  as  well  as  the  eyelids,  are  also  remarkable  for  their  sensitive- 
ness to  cold  and  heat.     We  meet  with  patients  who  have  several  times 


200  CLINICAL    TREATISE    ON 

suffered  from  rheumatic  paralysis  of  both  halves  of  the  face,  but  very 
rarely  upon  one  side  alone. 

According  to  Wachsmuth,  irritation  from  cold  will  affect  the  vaso- 
motor-fibres,  which  are  very  much  exposed  at  their  entrance  into  the  stylo- 
mastoid foramen.  This  causes  a  retardation,  perhaps  even  suppression 
of  the  flow  of  blood  to  the  facial  nerve,  with  rapid  abolition  of  excitabil- 
ity, formication  and  metallic  taste.  According  to  CI.  Bernard's  experi- 
ments, these  phenomena  are  dependent  upon  the  fibres  of  the  sympathetic, 
which  unite  with  the  chorda  tympani  at  various  points. 

The  symptoms  of  unilateral  facial  paralysis  are  evident,  to  a  certain 
extent,  at  the  first  glance.  The  paralyzed  cheek  is  sunken,  flaccid,  and 
expressionless,  the  characteristic  grooves  and  ridges  are  effaced.  The 
forehead,  upon  the  paralyzed  side,  appears  smoother  and  higher,  cannot 
be  made  to  frown,  and  the  eyebrows  cannot  approach  one  another.  On 
account  of  the  paralysis  of  the  orbicularis  palpebrserum,  the  lids  cannot 
be  closed  voluntarily;  the  lower  lid  droops,  the  palpebral  fissure  is  open 
(lagophthalmos),  the  eye  weeps  freely;  the  wing  of  the  nose  is  flattened, 
the  labio-nasal  fold  is  effaced,  the  labial  commissure  drawn  towards  the 
sound  side;  on  account  of  the  unilateral  paralysis  of  the  orbicularis  oris, 
the  mouth  is  only  partially  closed,  so  that  the  saliva  and  liquids  flow  out 
at  the  side.  The  movements  of  the  lips  in  whistling,  blowing,  sucking,  or 
expectorating,  and  the  pronunciation  of  labials,  are  embarrassed  or  ren- 
dered entirely  impossible.  On  account  of  the  relaxation  of  the  buccinator, 
food  readily  lodges  between  the  cheek  and  teeth,  and  the  patient  is  then 
obliged  to  remove  it  with  the  fingers  (cats  also  perform  this  movement 
with  the  paws  after  section  of  the  facial).  Every  marked  effort  of  the 
facial  muscles,  as  in  laughing  and  talking,  causes  a  more  decided  appear- 
ance of  deformity. 

Facial  paralysis,  like  peripheral  paralysis  in  general,  presents  great 
variations  in  the  symptoms,  which  have  been  studied  by  Ziemssen  (in  his 
work  upon  Electricity,  1866),  and  more  recently  by  Erb  (Arch.  f.  klin. 
Med.,  XV.  Bd.,  1  H.,  1874). 

The  peculiarities  and  modifications  of  the  electrical  phenomena  in 
rheumatic  facial  paralysis  are  interesting,  not  only  from  a  theoretical  but 
also  from  a  practical  point  of  view. 

Electrical  exploration  in  rheumatic  facial  paralysis  enables  us  to  de- 
termine various  degrees  of  change  in  the  nerves  and  muscles.  In  mild 
forms  (from  simple  swelling  of  the  periosteum  in  the  Fallopian  aqueduct), 
the  muscles  and  nerve-fibres  do  not  present,  even  after  the  lapse  of  a 
week,  any  appreciable  modification  of  their  faradic  and  galvanic  excitabil- 
ity. In  moderately  severe  forms,  the  electrical  excitability  of  the  nerve- 
fibres  is  simply  diminished,  the  farado-muscular  contractility  is  abolished, 
and  the  galvano-muscular  contractility  increased;  in  all  these  cases,  there 
are  slight  changes  in  the  nerves,  which  affect  their  electrical  excitability 
but  slightly,  while  in  the  muscles  profound  changes  develop  with  which 
we  are  already  acquainted.  In  severe  forms  (with  facial  neuritis),  both 
nerves  and  muscles  present  very  marked  changes.  In  the  nerves,  the 
faradic  and  galvanic  excitability  diminish  from  the  beginning  of  the  par- 
alysis until  they  completely  disappear;  the  nerve  may,  nevertheless,  pre- 
serve its  galvanic  excitability  in  some  branches.  The  return  of  the  ex- 
citability of  the  nerves  occupies  a  longer  or  shorter  period,  irrespective 
of  their  excitability  to  the  will.  In  the  muscles,  the  faradic  and  galvanic 
reactions  diminish  at  the  beginning  of  the  paralj^sis.  From  the  end  of 
the  second  week,  the  faradic  excitability  disappears,  while  the  galvanic 


DISEASES    OF   THE    NERVOUS    SYSTEM.  201 

excitability  increases  (Baierlacher,  Schulz,  Neumann,  Ziemssen,  Ro- 
senthal, Erb,  Eulenburg).  According  to  Erb,  the  mechanical  excitability 
is  also  increased.  In  proportion  as  improvement  progresses,  the  effects 
of  the  galvanic  current  diminish,  and  the  reactions  of  the  muscles  to  the 
faradic  current  and  to  the  will  usually  increase. 

Neumann  and  Koenigsberg  first  pointed  out  the  following  facts  with  regard  to  the 
physiological  reason  of  these  peculiar  electrical  phenomena  (they  are  also  produced 
in  lead  and  traumatic  paralyses)  :  if  there  is  absence  of  farado-muscular  with  preser- 
vation of  galvano-muscular  excitability,  this  peculiar  phenomenon  is  recognized  in  a 
definite  manner,  not  by  currents  of  different  direction  which  rapidly  follow  one  an- 
other, nor  by  reversal  of  the  current,  but  only  by  one  of  a  certain  duration,  such 
as  the  constant  galvanic  current.  If  the  galvanic  current  is  rendered  almost  instanta- 
neous by  means  of  any  mechanism,  no  contractions  wül  be  produced.  Similar  pe- 
culiarities were  then  observed  by  Neumann  upon  exhausted  muscles  and  by  Bruecke 
upon  frogs  poisoned  with  curare.  Much  weaker  induction  currents  were  required  in 
a  foot  which  had  been  previously  tied,  than  in  one  which  had  been  subjected  to  the 
action  of  the  poison,  while  the  latter,  on  the  other  hand,  reacted  to  weak  currents 
of  a  galvanic  pile.  The  galvanic  current  of  a  rapidly  rotated  Volta's  wheel  produced 
tetanus  of  the  intact  limb  while  the  poisoned  limb  remained  quiet. 

The  prognosis  of  rheumatic  facial  paralyses  is  usually  favorable.  In 
children  and  in  young,  healthy  individuals,  facial  paralysis  from  exposure 
often  recovers  spontaneously.  In  these  forms,  no  marked  modification 
of  faradic  and  galvanic  contractility,  or  of  the  excitability  of  the  nerve- 
fibres,  is  observed  during  the  first  and  second  weeks.  The  moderate 
forms  (with  slight  diminution  of  the  excitability  of  the  nerves,  abolition 
of  the  faradic  reaction  of  the  muscles,  increase  of  their  galvanic  reaction) 
terminated  favorably  at  the  end  of  four  or  six  weeks.  In  severe  cases 
(with  complete  abolition  of  the  excitability  of  the  nerves  and  abnormal 
electrical  reactions  in  the  paralyzed  muscles),  there  are  serious  disturb- 
ances of  nutrition  (neuritis),  the  repair  of  which  demands  weeks  or  even 
months  (six  to  nine  months).  Certain  facial  paralyses  of  the  latter  class 
pass  into  a  chronic  stage  and  become  incurable.  Electrical  treatment 
will  then  merely  improve  the  play  of  the  features  and  diminish  the  dis- 
tressing sensation  of  muscular  tension.  The  treatment  consists,  in  recent 
cases,  of  vapor  baths  followed  by  a  facial  douche  of  moderate  tempera- 
ture, and  the  internal  administration  of  iodide  of  potassium.  In  old 
forms,  strychnia,  administered  with  the  necessary  precautions,  gives 
good  results  (endermic  or  hypodermic  method,  doses  of  two  to  five  milli- 
grammes in  adults,  and  less  in  children).  But  electrical  treatment  con- 
stitutes the  most  efficient  remedy  at  our  command. 

In  recent  cases,  we  may  employ  the  secondary  induction  current,  for 
three  to  five  minutes  at  a  sitting,  to  the  paralyzed  muscles  or  nerve- 
fibres.  We  must  avoid  the  use  of  currents  with  strong  tension  and  rapid 
interruptions,  since  they  may  produce  electrical  muscular  stiffness  from 
over-stimulation.  In  order  to  relieve  deformities  which  may  have  been 
acquired  during  treatment,  we  may  use,  according  to  Remak,  stabile 
constant  currents  of  ten  to  twenty  Siemens'  elements.  Recent  contrac- 
tures may  disappear  under  the  use  of  this  measure,  but  old  ones  can 
only  be  corrected  by  myotomy  or  by  producing  faradic  contracture  of 
the  homologous  muscle  (Duchenne).  In  applying  the  galvanic  current, 
the  anode  is  placed  upon  the  cervical  vertebrae  and  the  cathode  upon  the 
paralyzed  muscles.  In  order  to  stimulate  the  facial  nerve  or  its  branches 
the  anode  is  placed  in  the  mastoid  fossa  and  the  cathode  is  moved  over 
the  pes  anserinus  or  the  other  nerve-fibres  (upon  the  temple  for  the  supe- 
rior muscles,  outside  of  the  zygomatic  arch  for  the  lids  and  upper  lip, 
upon  the  ramus  of  the  jaw  for  the  chin  and  lower  lip.     (Fig.  20.) 


202 


CLINICAL   TREATISE    ON 


M.  )iyramidal.  pasl. 

M.  orbicular,  jialpcbr. 

M.   levator  lab.    pup.  alsequi 

nasi. 
M.  levator  lab.  sup.  propr. 

M.  z3gomatic.  minor 

M.  dilatat.  narium  — 
M.  zygomatic,  major 
JI.  oibicularis  oris 


M.  frontalis. 
jtrMm.   retrahens  et  attollenlj 


Mnsc.  occipiir.lis. 


Ram.  pro  M.  levator  menti 

M.  levator  menti 
M.  qua(ir:itus  menti 
M.  triangularis  menti 
Rami  subcutan,  coll 

Rami  cervical,  pro  Platysmat 
II.  sternohyoidcus 
J[.  omohyoideus 
M.  sternothyroideiis 


M.  stemohyoideus 


Nerv,  facialis. 


■^I.  splenius  capiti?. 

Ram.  subcutan,  maxill.  inf. 

Ram.  ext.  N.  accossorii. 
M.  sternomastoideus. 
M.  cucullaris. 

-M.  sternomastoideus. 


M.  lev.  anguli  scapulEB. 

thoracic,  post. 

(Mm.  rhomboidel 

N.  phrenicus. 
M.  omohyoid. 

thoracic,  lateral. 
(M.  serrat.  mag 


N.  axillaria 


N.  thoracic,  ant 
(M.  pectorales.) 


Pio.  20.— Motor  points  of  face,  showing  the  position  of  the  electrodes  in  electrization  of  the  facial 
nerves  and  muscles.  The  anode  is  placed  in  the  mastoid  fossa,  and  the  cathode  upon  the  part  indicated  in 
the  figure. 


DISEASES    OF    THE    NERVOUS    SYSTEM.  203 

Galvanic  stimulation  of  the  buccal  cavity  (the  anode  upon  the  mucous 
membrane  of  the  cheek,  the  cathode  upon  the  paralyzed  muscles)  recom- 
mends itself,  according  to  my  observations,  on  account  of  the  more  ready 
penetration  of  the  current  into  the  muscular  layers,  and  because  it  re- 
quires a  smaller  number  of  elements  to  produce  contractions,  a  matter  of 
importance  in  the  neighborhood  of  the  eye.  In  obstinate  cases,  which 
are  complicated  by  deformities  of  the  face,  it  is  advisable  to  alternate 
galvanization  of  the  nerves  with  faradization  of  the  muscles.  Landois 
and  Mosler  cured  one  of  these  cases  (Berl.  klin.  "VYschr.,  18G8)  by  simul- 
taneously applying  a  descending  galvanic  current,  and  an  induced  cur- 
rent at  the  negative  pole  (electro-tonic  faradization). 

4.  Traumatic  facial  paralysis  results  from  various  lesions,  such  as  punc- 
ture, sword-cut,  gunshot  wound,  blows  upon  the  cheeks  (Brodie),  com- 
pression by  forceps,  section  of  the  nerve  in  operations,  compression  by  tu- 
mors and  deep  cicatrices  (as  in  suppurations  of  the  parotid).  According 
to  the  intensity  of  the  traumatic  cause,  there  will  be  complete  facial  pa- 
ralysis or  merely  paralysis  of  certain  branches  and  of  the  corresponding 
muscles. 

In  the  anthropoid  apes,  in  whom  the  mouth  is  also  closed  by  a 
sphincter,  facial  paralysis  acts  as  in  man  (Shaw  and  Bell),  while  in  dogs, 
cats,  and  rabbits,  section  of  the  facial  nerve  causes  a  deviation  of  the  face 
towards  the  paralyzed  side.  Schiff  explains  this  by  the  fact  that  there  is 
a  solution  of  continuity  in  the  sphincter  of  the  upper  lip,  which  thus  forms 
a  sort  of  natural  hare-lip.  In  two  half-grown  rabbits,  in  whom  Bruecke 
(Vorles.  u.  Physiol.,  II.  Bd.,  1873)  had  extirpated  the  facial  nerve  at  its 
exit  from  the  Fallopian  aqueduct,  Schauta  found,  at  the  end  of  several 
months,  a  paralysis  of  the  corresponding  half  of  the  face  with  loss  of  fara- 
dic  and  increase  of  galvanic  excitability.  In  one  of  these  animals,  the 
paralyzed  muscles  were  found  atrophied  with  disappearance  of  the  trans- 
verse strine  and  production  of  connective  tissue. 

To  judge  from  two  of  my  observations,  and  from  a  case  published  by 
Ziemssen,  the  voluntary  movements  and  faradic  excitability  disappear  in 
those  muscles  to  which  the  injured  nerve-fibres  are  distributed,  with  pres- 
ervation and  often  with  increase  of  the  galvanic  excitability  in  the  first 
weeks  which  follow  section  of  the  facial. 

These  remarks  are  confirmed  by  Erb's  observations  upon  beginning 
muscular  degenerations  following  section  of  the  nerves. 

The  nerve-fibres  lose  their  irritability  to  both  currents.  Stimulation 
of  the  nerve-trunk  only  produces  contractions  in  those  muscles  which  re- 
spond to  the  faradic  current;  some  muscles  react  to  the  will  but  not  to 
electrical  stimulation. 

As  the  conducting  power  of  the  nerves  is  gradually  re-established,  their 
electrical  irritability  usually  reappears  more  quickly  in  the  trunk  than  in 
its  branches.  In  the  beginning,  there  may  be  increase  of  reaction  to  the 
galvanic  current  and  of  electro-muscular  sensibility. 

Pathological  data  agree  with  the  results  of  experimentation.  After 
killing  the  nerves  with  curare  or  the  vapor  of  conicine,  we  also  find  the 
nervous  irritability  disappear,  although  the  muscles  preserve  their  electri- 
cal reactions  (Schiff,  Wundt,  Fick,  Bruecke). 

Traumatic  facial  paralyses  are  very  rebellious  and  require  months  for 
the  completion  of  recovery,  voluntary  motion  being  re-established  more 
rapidly  than  the  electrical  excitability.  The  best  method  of  treatment  is 
the  alternate  use  of  the  constant  and  induced  currents. 

5.  Syphilitic  facial  paralyses,  when  they  result  from  an  affection  of  the 


204  CLINICAL   TREATISE    ON 

cerebral  substance,  assume  the  characteristics  of  intra-cerebral  paralyses. 
On  the  other  hand,  specific  lesions  of  the  facial  nerve  at  the  base  of  the 
brain  are  of  a  peripheral  nature,  according  to  the  electrical  investigations 
of  Ziemssen  (Virch.  Arch.,  13  Bd.,  1858). 

In  the  patient  in  question,  after  the  appearance  of  secondary  syphilis,  diplopia  de- 
veloped, followed  by  complete  paralysis  of  the  right  facial  nerve,  the  patheticus,  both 
external  motor-oculi,  incomplete  paralysis  of  the  facial  and  motor  oculi  communis  on 
the  left  side,  and  of  the  majority  of  the  flexors  and  extensors  of  the  hand.  Faradio 
exploration  showed  an  abolition  of  electrical  contractility  in  the  paralyzed  muscles, 
and  a  considerable  diminution  in  the  muscles  which  were  merely  paretic  (this  con- 
firmed the  diagnosis  of  an  extra-cerebral  syphilitic  affection).  At  the  autopsy,  the  re- 
mains of  a  chronic  inflammation  of  the  pia  mater  were  found  at  the  base  of  the  brain, 
attended  with  exudation  and  formation  of  connective  tissue,  the  retraction  of  which 
had  strangulated  the  facial  nerve  ;  in  the  central  end  there  was  a  moderate  accumula- 
tion of  fatty  granules,  and,  in  the  peripheral  portion  a  degeneration  corresponding  to 
the  compression  ;  the  paralyzed  muscles  had  undergone  fatty  degeneration. 

In  one  of  my  observations,  after  several  relapses  of  syphilis,  periostitis 
occurred  in  the  tibia  and  in  the  mastoid  process  of  the  left  temporal  bone; 
the  left  facial  nerve  was  paral^'zed,  with  the  exception  of  its  upper  branch. 
The  nerve-trunk  did  not  respond  to  the  faradic  current,  and  the  muscles 
only  contracted  feebly.  Davaine  published  a  case  which  was  similar  to 
this  in  several  respects. 

In  another  case  observed  at  Prof.  Sigmund's  clinic,  the  faradic  excita- 
bility of  the  nerve-trunk,  like  that  of  the  muscles,  was  abolished  in  the 
paralyzed  half  of  the  face.  Although  the  galvanic  current  produced  mus- 
cular contractions,  the  irritability  of  the  nerve-trunks  had,  on  the  other 
hand,  considerably  diminished,  and  was  only  manifested  with  a  very 
strong  current  (twenty-four  Siemens'  elements).  These  facts  led  me  to 
diagnose  a  morbid  process  compressing  the  nerve-trunk  itself  (probably 
in  the  bony  canal  of  the  nerve).  The  examination  of  the  ear  had  been 
previously  made  by  a  specialist.  Dr.  Gruber,  who  determined  the  exist- 
ence of  syphilitic  otitis  with  exudation  into  the  Fallopian  aqueduct,  but 
without  lesion  of  the  tympanum. 

6.  I  have  seen  one  case  of  diphtheritic  facial  paralysis  {vide  p.  149, 
Vol.  T.),  in  which  electrical  exploration  gave  the  same  results  as  in  peri- 
pheral paralysis. 

We  shall  now  mention  the  principal  complications  which  may  occur  in 
the  various  kinds  of  peripheral  facial  paralysis,  and  which  are  important 
in  diagnosing  the  position  at  which  the  nerve-fibres  are  affected. 

a.  Paralysis  of  the  posterior  auricular  nerve,  with  abolition  of  the 
functions  of  the  occipital  nerve  and  of  the  retractor  muscles  of  the  ear  on 
the  paralyzed  side.  Erb  has  recently  discovered  (loc.  cit.)  a  much  more 
characteristic  sign  of  this  paralysis,  viz.:  abolition  of  faradic  and  increase 
of  the  galvanic  excitability  of  the  muscles.  This  paralysis  indicates  that 
the  lesion  is  situated  outside  of  the  Fallopian  aqueduct. 

b.  Paralysis  of  the  chorda  tympani:  According  to  the  views  expressed 
in  the  preceding  chapters,  the  fibres  of  the  chorda  tympani,  contained  in 
the  facial,  furnish  the  sense  of  taste  to  the  anterior  portion  of  the  tongue. 
Numerous  examples  of  facial  hemiplegia  attended  with  abolition  or  dimi- 
nution of  taste  in  the  corresponding  half  of  the  tongue,  are  found  in  old 
and  recent  medical  literature. 

I  have  reported  (W.  Med.  Presse,  1868,  obs.  7)  a  case  of  rheumatic 
facial  paralysis  on  the  left  side,  with  cephalalgia,  noises  in  the  ears,  and 
tingling  in  the  tongue;  upon  rubbing  the  left  half  of  the  tongue  with 
powdered  sugar,  or  upon  smearing  it  with  syrup,  the  patient  perceived 


DISEASES    OF   THE    NEEVOUS    SYSTEM.  205 

an  acid  taste;  crystals  of  sulphate  of  magnesia  appeared  acid  and  bitter, 
and  the  tincture  of  opium  also  tasted  bitter;  on  the  right  side,  gustation 
was  normal.  The  salivary  secretion  is  sometimes  diminished  (with  a  sen- 
sation of  unilateral  dryness),  a  fact  which  is  explained  by  the  simultane- 
ous implication  of  the  secretory  nerves  which  the  facial  sends  to  the  par- 
otid and  submaxillary  glands.  The  preceding  symptoms  indicate  that  the 
lesion  is  situated  in  the  Fallopian  canal,  above  the  point  of  emergence  of 
the  chorda  tympani. 

c.  The  paralysis  of  the  nerve  supplying  the  stapedius  below  the  geni- 
culate ganglion  produces  hyperakusia  (Willis)  or  hyperesthesia  of  hear- 
ing, and  has  been  observed  by  Roux,  Wolf,  and  Landouzy,  and  more  re- 
cently by  Hitzig  and  Lucae.  The  subject  was  discussed  in  detail  in  a 
preceding  chapter  on  neuroses  of  the  acoustic  nerve. 

d.  Paralysis  of  the  nervus  petrosus  superficialis  major:  In  addition 
to  the  paralysis  of  the  external  muscles  of  the  face,  a  deviation  of  the 
velum  palati  with  difficulty  of  movement  in  it  has  been  observed,  together 
with  an  alteration  in  taste.  The  site  of  the  lesion  is  at  the  intumescentia 
gangliformis,  at  the  entrance  of  the  gustatory  fibres  and  exit  of  the  motor 
fibres  of  the  pillars  of  the  palate.  Mere  deviation  of  the  uvula  is  unim- 
portant, as  we  have  previously  shown. 

e.  We  may  finally  mention  difficulty  of  hearing  with  abnormal  acous- 
tic reactions.  Acoustic  hyperaesthesia  with  abnormal  reactions  is  also  ob- 
served at  times. 

In  conclusion,  it  only  remains  for  us  to  discuss  double  facial  paralysis. 

Bilateral  paralysis,  which  was  recognized  by  Bell,  Sanders,  Grisolle, 
and  Romberg,  has  been  more  thoroughly  investigated  by  Davaine,  Trous- 
seau, and  Wachsmuth.  According  to  Schiff,  if  both  facial  nerves  are 
divided,  the  animals  are  unable  to  close  the  mouth,  the  cheeks  remain 
flaccid  even  during  the  movements  of  mastication,  the  food  introduced 
into  the  mouth  in  part  falls  outside,  while  another  part  lodges  between 
the  cheeks  and  gums.  Hence  arises  great  difficulty  in  the  formation  of 
the  alimentary  bolus  and  in  deglutition.  In  man,  facial  diplegia  causes 
immobility  of  the  face  and  fixity  of  the  features;  the  cheeks  and  labial 
commissures  are  drooping;  the  alai  nasi,  deprived  of  mobility,  collapse 
mechanically  during  deep  inspirations,  together  with  the  cheeks,  which 
are  also  pulled  out  by  the  expired  air.  The  nasal  character  of  the  voice 
and  the  defective  pronunciation  of  the  labials  render  speech  almost  unin- 
telligible; when  the  head  is  slightly  bent  forwards,  the  salvia  trickles  out 
between  the  opened  lips.  Mastication  and  deglutition  are  greatly  inter- 
fered with,  the  food  is  arrested  in  its  passage  and  the  patients  are  obliged 
to  push  it  into  the  pharynx  with  the  fingers. 

The  central  form  of  facial  diplegia  is  sometimes  observed  in  labio- 
glosso-pharyngeal  paralysis  (from  implication  of  the  facial  nuclei);  it  may 
exist  to  a  less  marked  extent  in  certain  chronic  cerebral  diseases.  The 
paralysis  may  also  be  peripheral  and  due  to  various  intra-cranial,  but 
extra-cerebral,  affections  of  the  facial  nerves.  Thus,  basilar  tumors,  exos- 
toses of  the  basilar  process,  aneurisms,  and  meningeal  exudations,  may 
produce  atrophic  degeneration  of  the  facial  nerves  from  compression,  and 
the  adjacent  nerves  do  not  always  escape.  According  to  Jaccoud  and 
Pierreson  (Arch.  Gen.,  II.  Bd.,  1867)  the  facial,  like  other  nerves,  some- 
times atrophies  spontaneously  from  hyperplasia  of  the  connective-tissue 
and  development  of  amyloid  corpuscles.  Peripheral  facial  diplegia  may 
also  be  due  to  disease  of  the  petrous  portion  of  the  temporal  bone  (inflam- 
mation, caries,  necrosis,  or  syphilitic  otitis). 


206  CLINICAL   TREATISE    ON 

In  a  case  observed  by  Ehrmann,  double  facial  paralysis  followed  bilate- 
ral tubercular  otitis.  The  autopsy  revealed  simply  caries  of  the  middle  ear, 
the  Fallopian  canals  being  perfectly  intact;  the  neurilemma  of  the  nerves 
contained  a  large  number  of  pus  globules  (participation  of  the  sheath  of  the 
nerve  in  the  inflammation  of  the  middle  ear).  Finally,  facial  diplegia  may 
be  of  rheumatic  origin,  the  cold  either  acting  at  the  same  time  upon  both 
halves  of  the  face,  or  the  paralysis  involving  first  one  side  and  then  the  other. 

The  diagnosis  of  peripheral  facial  diplegia  does  not  present  any  diffi- 
culties, if  we  are  able  to  eliminate  central  causes.  In  double  facial  paral- 
ysis of  rheumatic  origin,  the  movements  of  the  tongue  and  the  timbre  of 
the  voice  are  unaltered,  and  the  disturbances  of  deglutition  diminish  when 
the  nares  are  closed.  The  j^i'ognosis  depends  upon  the  nature  of  the  dis- 
ease. TVeatment  may  be  ineffectual  in  certain  peripheral  forms.  In  a 
case  of  double  paralysis  of  the  face  published  by  Baerwinkel  (Arch.  f. 
Heilk.,  I.  Bd.,  1867),  the  paralyzed  muscles  on  the  right  side  were  insen- 
sible to  the  faradic,  but  sensible  to  the  galvanic  current;  on  the  left  side, 
the  electrical  reactions  were  normal.  Cephalalgia,  diplopia,  and  uncer- 
tainty of  gait  were  also  present.  After  ten  months  of  electrical  treat- 
ment, recovery  was  almost  complete. 

c.  Diseases  of  the  Hypoglossal  Nerve. 

Spasms  involving  the  territory  of  the  hypoglossal  nerve  are  very  rarely 
of  a  peripheral  nature.  As  a  rule,  they  accompany  serious  disorders,  such 
as  epilepsy,  hysteria,  chorea,  meningitis.  Partial  clonic  spasms  (fibrillary 
tremor)  sometimes  occur  in  progressive  muscular  atrophy,  neuralgias  of 
the  lingual  nerve  and  convulsive  tic.  The  spasms  of  the  tongue  are,  there- 
fore, due  either  to  central  or  peripheral  causes. 

Paralysis  of  the  hypoglossal  nerve  is  also  rarely  of  peripheral  origin, 
as  in  tumors  at  the  base  of  the  brain,  compression  of  the  hyi^oglossus 
at  its  point  of  emergence,  and  in  extirpation  of  tumors  of  the  tongue, 
when  some  fibres  of  the  nerve  have  been  injured  in  the  operation. 
Paralysis  of  the  tongue  is  usually  unilateral,  of  central  origin,  and  is  ob- 
served in  hcemorrhage,  embolism,  softening,  cerebral  tumors,  progressive 
paralysis  of  the  insane;  in  labio-glosso-pharyngeal  paralysis,  it  may  pre- 
sent various  stages  up  to  complete  abolition  of  motion;  in  progressive 
muscular  atrophy,  it  is  accompanied  by  signs  of  atrophy. 

After  section  of  the  hypoglossus  in  animals  and  in  unilateral  glosso- 
plegia  in  man,  the  tongue  when  protruded  deviates  to  the  diseased  side. 
Schiff  attributes  this  fact  to  the  predominance  of  the  genio-glossus  on  the 
sound  side,  which  directs  the  tip  of  the  tongue  towards  the  opposite  side. 
When  the  tongue  is  drawn  backwards,  the  action  of  the  stylo-glossus  draws 
it  towards  the  sound  side. 

Paralysis  of  the  tongue,  in  its  various  forms,  should  not  be  mistaken 
for  those  cases  in  which  language  is  affected  by  disorders  of  co-ordination, 
or  by  disturbance  of  the  centrifugal  conducting  power,  as  in  localized 
affections  of  the  motor  ganglia,  pons  and  floor  of  the  fourth  ventricle  (le- 
sions of  the  nucleus  of  the  hypoglossus  or  of  its  ascending  root-fibres). 

T\\e  prognosis  is  unfavorable  in  the  majority  of  cases.  The  treatment 
of  lingual  paralysis  consists  in  the  restoration  of  the  energy  of  the  nerve- 
centres.  The  functions  of  the  tongue  may  sometimes  be  improved  by 
the  prudent  application  of  the  galvanic  current  through  the  head,  or  by 
combining  local  faradization  or  galvanization  of  the  tongue  and  hypoglos- 
sus with  invigorating  hydro-therapeutic  measures. 


DISEASES    OF   THE    NERVOUS    SYSTEM.  207 


CHAPTER  XLVI. 
C. — Diseases  of  the  Mixed  Ceanial  Nerves. 
(Trigeminus,  Pneumogastric,  Spinal  Accessory.) 


a.  Diseases  of  the  Trigeminal  Nerve. 

The  various  affections  of  the  fifth  pair  of  nerves  include  neuralgia  or 
anaesthesia  of  the  sensory  branches,  and  tonic  or  clonic  spasms,  and  para- 
lysis of  the  third  branch. 


1.    NEURALGIA  OP   THE   TRIGEMINUS. 

Neuralgia  of  the  different  branches  of  the  trigeminal  nerve  (proso- 
palgia, facial  pain  of  Fothergill,  tic-douloureux)  has  attracted  the  atten- 
tion of  physicians  since  a  very  early  period. 

The  anatomical  changes  in  the  nerve  or  its  surrounding  tissues  in 
prosopalgia,  embrace  the  following  lesions  :  chronic  hypertemia  and  red- 
ness of  the  neurilemma,  thickening  of  the  neurilemma  following  neuritis, 
partial  granular  degeneration  of  the  myeline,  enlargements  and  nodosities 
upon  resected  branches  of  the  nerve  (connective  tissue  enclosing  the 
nerve  fibres  as  in  the  enlargement  of  the  nerves  in  amputation  stumps), 
periostitis,  concentric  hypertrophy  (Gross),  osteophytes  or  caries  of  the 
osseous  canals,  exostoses  upon  the  roots  of  the  wisdom  tooth  (Thompson, 
Glasgow  Med.  Journ.,  1867),  very  rarely  exostoses  in  the  cranial  cavity 
or  upon  the  petrous  portion  of  the  temporal  bone,  which  penetrate  into  the 
Gasserian  ganglion  (Chouppe).  Finally,  inflammatory  changes  may  be 
found  in  the  various  ganglia  of  the  trigeminus:  the  spheno-palatine 
ganglion  (Carnochan),  Gasserian  ganglion  (Wedl's  case,  with  calcareous 
degeneration  and  considerable  development  of  vessels),  neuroma  of  the 
Gasserian  ganglion  with  a  prolongation  through  the  dilated  foramen 
ovale,  finally,  compression  of  the  trigeminus  by  cerebral  neoplasms.  In 
many  cases  of  prosopalgia,  no  organic  changes  were  found  in  the  nerves, 
but  the  number  of  these  cases  will  diminish  as  microscopical  examinations 
are  more  frequently  made. 

Among  the  symptoms  of  tic-douloureux,  pain  is  the  most  important. 
Very  frequently,  a  more  or  less  disagreeable  sensation  may  exist  for  a 
long  time  before  the  development  of  a  true  paroxysm.  In  some  cases, 
however,  the  paroxysm  develops  suddenly.  The  pain  is  usually  extreme- 
ly violent,  and  the  patients  describe  it  as  burning,  piercing,  shooting,  or 
compare  it  to  a  concussion  of  the  brain.  The  pains  often  appear  spon- 
taneously or  they  are  produced  by  excitement,  slight  friction,  or  pricking 


208  CLINICAL   TEEATISE    ON 

of  the  cheeks,  a  gentle  current  of  air,  or  even  by  speaking.  One  of  the 
most  distressing  forms  is  that  in  which  the  pains  are  called  forth  by  the 
movements  of  mastication  and  deglutition.  The  patients  hardly  dare 
swallow  a  little  fluid  food  and  neglect  cleansing  the  mouth,  thus  causing 
a  bad  odor  from  the  accumulation  of  tartar. 

The  pain  of  prosopalgia  may  be  continuous,  in  which  event  it  is  mani- 
fested with  less  violence,  and  by  a  sensation  of  compression  or  burning, 
or  it  may  appear  in  the  form  of  dreaded  paroxysms,  increasing  in  inten- 
sity and  frequency,  and  very  frequently  radiating  from  certain  points 
towards  the  centre,  more  rarely  towards  the  periphery.  The  continuous 
pains  are  usually  found  in  certain  situations  which  have  been  called 
puncta  dolorosa  by  Valleix.  These  include,  in  the  course  of  the  first 
branch:  a  frontal  point  at  the  emergence  of  the  frontal  nerve,  a  palpe- 
bral point  upon  the  upper  lid,  a  supraorbital  point,  corresponding  to  the 
nerve  of  the  same  name,  a  point  at  the  outer  angle  of  the  eye,  pertaining 
to  the  lachrymal  nerve,  and  two  points  upon  the  lateral  surface  of  the 
nose,  an  upper  one,  corresponding  to  the  inner  angle  of  the  eye  and  along 
the  subtrochlear  nerve,  and  a  lower  one,  at  the  union  of  the  nasal  bone 
and  triangular  cartilage,  corresponding  to  the  ethmoidal  nerve.  In  the 
territory  of  the  second  branch  are  found:  the  infraorbital  point  (for  the 
nerve  of  the  same  name),  a  malar  point  over  the  zygomatic  arch,  a  maxil- 
lary point  at  the  anterior  border  of  the  masseter  muscle  (corresponding 
to  a  filament  of  the  pterygo-palatine  nerve),  a  palatine  point  for  the 
descending  palatine  nerve,  and  a  gengival  point  upon  the  anterior  or 
posterior  surface  of  the  gums,  corresponding  to  the  anterior,  median,  or 
posterior  branches  of  the  superior  dental  nerve.  In  the  course  of  the 
third  branch  are  found  the  following:  a  temporal  point  in  front  of  the 
tragus,  a  parietal  point  at  the  union  of  the  frontal,  superficial  temporal 
and  occipital  nerves,  a  maxillary  point  in  the  region  of  the  temporo-max- 
illary  articulation,  a  lingual  point  for  the  lingual  nerve,  and  a  mental 
point  upon  the  chin. 

Frequently,  the  patients  indicate  of  their  own  accord  these  painful 
points,  pressure  over  which  causes  excessive  sensibility,  which  may  in- 
crease until  a  paroxysm  appears.  Painful  points  are  also  found  upon 
pressure  over  the  spinous  and  transverse  processes  of  the  upper  cervical 
vertebrae  (Trousseau's  "  point  apophysaire ").  The  attacks  of  pain 
usually  start  from  the  puncta  dolorosa,  which  we  have  mentioned,  and 
then  extend  in  a  centripetal  or  centrifugal  direction.  In  certain  cases, 
however,  these  points  are  not  noticed  by  the  patients,  nor  can  they  be  de- 
tected in  the  intervals  between  the  paroxysms.  These  forms  of  neuralgia 
are  usually  of  central  origin. 

The  motor  and  vaso-motor  complications  of  prosopalgia  consist  of 
reflex  facial  spasms  upon  the  affected  side  (more  rarely  on  the  healthy 
side),  and  of  irradiated  sensations  in  the  occiput,  neck,  shoulder,  thorax, 
and  limbs.  Prosopalgia  is  also  accompanied  by  disorders  of  secretion, 
in  consequence  of  the  relations  of  the  branches  of  the  trigeminus  with 
the  vaso-motor  fibres.  In  neuralgia  of  the  first  branch,  they  consist  of 
an  increase  in  the  lachrymal  secretion,  especially  at  the  close  of  the 
paroxysm,  from  relaxation  of  the  vessels  of  the  lachrymal  gland;  in  af- 
fections of  the  second  and  third  branches,  of  a  hypersecretion  of  nasal 
mucus  and  saliva,  the  vessels  of  the  Schneiderian  membrane  being  in- 
nervated by  the  vaso-motor  fibres  of  the  trigeminus,  and  the  latter 
stimulating,  by  reflex  means,  the  submaxillary  gland  (according  to  Lud- 
wig's  and  Rahn's  exp£riments).     A  secretion  of  sweat  also  occurs  upon 


DISEASES    OF   THE    NERVOUS    SYSTEM.  209 

the  affected  side  of  the  face,  the  trigeminus  containing  nerve-fibres  going 
to  the  cutaneous  vessels. 

Other  vaso-motor  disturbances  may  also  occur  in  neuralgias  of  the 
fifth  pair,  such  as  swelling,  redness,  elevation  of  temperature  upon  the 
aiiected  side  (Schuh),  and  a  tendency  to  erysipelatous  inflammations  (An- 
stie).  Zona,  discoloration  of  the  face,  and  roughening  or  falling  out  of  the 
hairs,  are  sometimes  observed.  Ophthalmia,  due  to  an  affection  of  the 
trigeminus,  has  been  discussed  in  the  chapter  on  tumors  of  the  base  of  the 
brain,  but  we  shall  again  recur  to  this  subject  in  detail.  Among  trophic 
disorders  Romberg,  Notta,  Brodie,  and  Niemeyer  have  observed  an  hyper- 
trophy of  the  affected  cheek.  Unilateral  atrophy  of  the  face,  which 
rarely  accompanies  neuralgia,  will  be  discussed  in  the  chapter  on  tro- 
phoneuroses. 

The  ccmses  of  the  disease  are  as  follows:  tumors  of  the  middle  cerebral 
fossa  and  of  the  base  of  the  brain  (with  neuralgia  in  case  of  prolonged 
irritation,  and  anjEsthesia  in  degeneration  of  the  nerves),  foci  of  suppu- 
ration, tumors  of  the  pons,  aneurisms  of  the  carotid  in  the  sella  turcica 
(Romberg),  and  morbid  processes  around  the  Gasserian  ganglion.  AVhile 
I  was  a  student  I  saw,  at  Schuh's  clinic,  a  case  of  prosopalgia  of  nine 
years'  duration;  the  mylo-hyoid  nerve  was  resected,  but  the  internal  max- 
illary artery  was  cut  during  the  operation  and  the  htemorrhage  necessi- 
tated the  ligature  of  the  primary  carotid.  The  patient  died  at  the  end  of 
four  months  from  purulent  infection,  and,  upon  autopsy,  a  steatoma  was 
found  as  large  as  a  hazel-nut  at  the  point  of  emergence  of  the  trigeminus, 
which  the  tumor  surrounded  like  a  ring.  Facial  neuralgias  sometimes 
occur  in  diseases  of  the  cervical  cord,  ataxia  and  hj-steria  (irritation  of  the 
fibres  of  the  trigeminus  which  originate  in  the  posterior  column  and  most 
inferior  portion  of  the  medulla  oblongata).  A  frequent  cause  of  neural- 
gia is  periostitis  of  the  bony  orifices  traversed  by  the  trigeminus.  Ac- 
cording to  Hyrtl,  the  branches  which  pass  through  narrow  osseous  canals 
(supraorbital,  infraorbital,  zygomatic,  superior  and  inferior  dental)  are 
often  affected  with  neuralgia,  while  those  which  have  free  exit  through 
the  spheno-palatine  fissure  are  rarely  involved.  We  have  previously 
referred  to  exostoses  of  the  cranial  bones  and  maxillfe  as  causes  of  this 
affection;  tumors  of  the  jaw  may  also  act  in  the  same  manner.  Exposure 
constitutes  the  most  frequent  among  the  occasional  causes. 

The  greatest  number  of  neuralgias  and  their  relapses  occur  in  the  cold  months. 
Next  to  sciatica,  neuralgia  of  the  trigeminus  is  most  frequently  produced  by  cold. 
Traumatism  (foreign  bodies,  cicatrices  following  wounds  of  the  face)  is  a  very  lare 
cause  of  this  affection. 

Women,  especially  in  early  life,  are  more  subject  to  tic-douloureux  than  men. 
The  largest  number  of  cases  occur  between  the  ages  of  thirty  and  fifty  years.  Nerv- 
ous individuals  of  an  irritable  temperament  possess  an  especial  predisposition.  Ex- 
amples of  heredity  are  very  rare.  We  sometimes  observe  at  an  advanced  age  intense 
facial  neuralgias,  accompanied  by  reflex  symptoms  and  an  abnormal  mental  irritability 
(Trousseau's  epileptiform  neuralgia).  Several  times,  also,  I  have  seen  old  men  (sixty 
to  seventy  years  of  age)  suffering  from  melancholia,  complicated  with  neuralgia  of  the 
dental  branches  ;  these  cases  must  be  attributed  to  senile  changes  in  the  tissues  (osseous 
canals  or  arteries).  In  malarial  districts  supraorbital  neuralgia  (metapcdynia)  ig  often 
observed,  running  the  course  of  intermittent  fever,  and  is  regarded  by  physicians  as  a 
latent  fever.  But  the  enlargement  of  the  spleen  is  almost  always  wanting  in  these 
cases,  and  when  it  exists,  may  be  due  to  a  previous  attack  of  intermittent  fever. 
Furthermore,  the  effects  of  quinine  do  not  establish  the  identity  of  these  neuralgias  with 
intermittent  fever,  but  the  drug  merely  acts  as  in  periodical  affections  in  general.  It 
is  more  proper,  therefore,  to  admit  that  the  influence  of  malaria  may  give  rise  to  certain 
Beural^ias  which,  by  their  febrile  and  intermittent  course,  present  analogies  with  in- 
termittent fever,  but  do  not  constitute  a  latent  form  of  the  latter  disease. 
Vol.  IL— 14 


210  CLINICAL    TREATISE    ON 

The  course  of  trigeminal  neuralgias  is  extremely  variable.  The  acute 
forms  present  a  very  regular  type  ;  on  the  other  hand  the  chronic  forms 
have  an  irregular  course  and  are  composed  of  a  series  of  attacks  following 
one  another  rapidly,  varying  from  thirty  seconds  to  one  minute  in  dura- 
tion, and  forming  in  reality  a  very  long  paroxysm.  The  patients  may  be 
thus  tormented  for  days  or  weeks,  then  the  pains  disappear  for  a  period 
which  is  often  quite  long,  to  reappear  again  under  the  influence  of  change 
of  weather,  a  draught  of  air  or  mental  excitement.  Not  infrequently  the 
disease  is  followed  by  general  excessive  hyperaesthesia  or  by  psychical 
disorders.  The  patient  is  often  a  veritable  martyr  and  is  sometimes  led 
to  commit  suicide. 

The  diagnosis  of  tic-douloureux  frequently  offers  great  difficulties, 
less  to  detect  the  neuralgia  than  to  determine  its  nature  and  origin.  The 
pains  correspond  to  the  anatomical  distribution  of  the  trigeminus,  occur 
in  paroxysms,  and  often  present  (but  not  always)  certain  painful  points. 
Its  intra-cerelDral  origin  is  chiefly  recognized  by  the  following  signs:  ab- 
sence of  the  puncta  dolorosa  in  the  intervals  between  the  paroxysms,  ap- 
pearance of  these  points  during  the  paroxysms,  general  excessive  hyper- 
aesthesia, extensive  reflex  muscular  contractions  (in  the  face  and  limbs) 
during  and  after  the  attacks,  psychical  excitement  or  depression.  When 
the  lesion  is  extra-cranial,  the  nerve-fibres  accessible  to  exploration  usu- 
ally present,  outside  of  the  paroxysms,  some  point  which  is  peculiarly 
sensitive,  and  pressure  upon  which  may  even  produce  a  paroxysm;  the 
pain  usually  occupies  the  distribution  of  a  certain  nerve-fibre  and  exam- 
ination sometimes  reveals  a  peripheral  affection.  In  many  cases,  the 
diagnosis  is  merely  possible  with  a  greater  or  less  amount  of  probability, 
and  we  can  only  arrive  at  greater  certainty  after  prolonged   observation. 

A  certain  amount  of  attention  is  often  necessary  in  order  to  avoid 
mistaking  prosopalgia  for  other  analogous  affections.  It  is  most  frequently 
mistaken  for  the  pain  arising  from  decayed  teeth,  but  a  careful  explora- 
tion of  the  teeth  by  means  of  a  sound  or  cold  water  will  soon  disclose  the 
diseased  tooth  or  root.  If  the  latter  is  removed,  the  pains  will  disap- 
pear, while  true  trigeminal  neuralgia  is  aggravated  by  extraction  of  the 
teeth.  Inflammation  of  the  temporo- maxillary  joint,  or  of  the  antrum  of 
Highmore  during  an  attack  of  coryza,  may  give  rise  to  acute  pains  in  the 
face,  but  they  are  not  situated  along  definite  nerve-fibres.  Their  origin 
is  furthermore  recognized  by  the  detection  of  swelling  or  distention  of 
the  inflamed  parts,  and  the  pains  disappear  after  spontaneous  or  artificial 
opening  of  the  abscess.  Migraine  (hemicrania)  is  distinguished  from  tic- 
douloureux  by  the  gradual  increase  of  the  pains,  the  shorter  duration  of 
the  attacks,  their  much  rarer  appearance,  their  renewal  at  the  menses, 
the  frequent  coexistence  of  vaso-motor  disturbances,  the  unilateral  dila- 
tation of  the  pupil,  by  the  frequent  appearance  of  vomiting,  and  finally 
by  the  absence  of  painful  points  which  are  usually  rqalaced  by  circum- 
scribed hypenissthesia.  The  pains  which  radiate  into  the  face  and  are 
sometimes  observed  in  chronic  leucorrhoea  and  uterine  diseases,  are  readily 
distinguished  from  prosopalgia  by  the  character  of  the  local  phenomena, 
the  absence  of  jnoicta  dolorosa,  and  by  the  general  hyperesthesia.  In 
Cerise's  case  (Annal.  Med.  Psychol.,  May,  1845),  the. facial  pain  disap- 
peared after  the  extirpation  of  a  fibroid  tumor  of  the  uterus. 

Neuralgias  of  the  fifth  pair,  due  to  cerebral  tumors,  are  complicated  by 
diplopia,  vertigo,  chronic  cephalalgia,  symptoms  of  neuro-retinitis,  spasms 
and  paralyses  in  the  limbs;  there  are  no  puncta  dolorosa  in  the  face.  In 
basilar  tumors,  in  which  trigeminal  neuralgia  usually  terminates  in  anaes- 


DISEASES    OF   TUE    NEEVOUS    SYSTEM.  211 

thesia,  other  adjacent  nerves  are  affected  at  the  same  time,  and  we  observe 
the  tumor  symptoms  with  which  we  are  already  acquainted.  Facial  pains 
in  spinal  affections  are  accompanied  by  vague  neuralgias  in  the  arms  or  legs, 
genital  irritation,  motor  exhaustion,  etc.  Hysterical  facial  neuralgias 
occur  in  company  with  other  characteristic  symptoms  of  hysteria,  and 
saturnine  pains  are  combined  with  other  signs  of  lead  poisoning. 

The  2^1'ognosis  varies  according  to  the  nature,  intensity,  and  chronicity 
of  the  neuralgia.  The  central  forms  will  not  yield  spontaneously  unless 
the  nerve  undergoes  destruction.  Acute,  periodical  facial  neuralgias 
offer  the  best  chances  of  recovery.  Among  the  chronic  cases  of  an  irreg- 
ular type,  those  in  which  the  pain  occupies  a  circumscribed  region  and  iu 
which  there  are  puncta  dolorosa,  may  be  improved  or  cured  by  a  surgical 
operation.  In  the  absence  of  these  symptoms  and  especially  when  the 
affection  has  lasted  for  a  long  time,  the  chances  of  recovery  diminish,  and 
many  of  these  cases  continue  for  life.  As  a  rule,  the  proportion  of  re- 
coveries is  greater  in  young  than  in  old  people. 

A  fatal  termination  is  extremely  rare,  but  the  pain,  insomnia,  and  in- 
sufficient alimentation  may  sometimes  give  rise  to  a  serious  diminution  of 
the  vital  energies.  In  certain  cases  in  which  surgical  interference  has 
been  resorted  to,  death  has  been  due  to  gangrene  of  the  wound  after 
operation,  to  metastatic  abscesses,  or  to  erysipelas  with  meningitis. 

In  the  treatment  of  prosopalgia  we  must  pay  especial  attention  to  the 
nature  of  the  affection.  In  recent  and  periodical  neuralgias,  benefit  is 
usually  derived  from  large  doses  of  quinine.  If  good  results  are  not  ob- 
tained after  this  treatment  has  been  continued  for  three  or  four  days,  it 
is  useless  to  continue  it.  Sometimes  the  combination  of  quinine  and 
opium  succeeds  better;  finall}^,  if  this  also  fails,  we  may  prescribe  five 
or  six  drops  of  Fowler's  solution  every  three  hours.  If  there  are  signs 
of  periostitis,  resort  must  be  had  to  iodide  of  potassium  and  to  local 
bleedings.  Iron  is  preferable  in  chlorotic  patients,  in  whom  facial  neu- 
ralgia is  merely  a  radiated  pain.  Metallic  preparations  have  almost  en- 
tirely lost  their  former  repute.  Ointments  of  veratrine  (Turnbull,  0.10- 
0.20  to  four  grammes)  or  of  aconitine  (Watson,  0.07-0.15  to  four 
grammes),  applied  for  several  minutes  over  the  seat  of  pain,  merely  pro- 
duce momentary  relief.  Fumigations  with  substances  rich  in  essential 
oils,  practised  dvaly  for  several  months  upon  the  affected  side  of  the  face, 
have  a  soothing  effect.  I  saw  one  case  recover  after  this  treatment  had 
been  continued  for  nine  months. 

In  chronic  forms  of  an  irregular  course,  derivatives  are  still  frequently 
employed  (revulsive  plasters,  Valleix'  flying  blisters,  Jobert's  transverse 
cauterization,  frictions  with  croton  oil).  Subcutaneous  injections  of  a 
strong  solution  of  nitrate  of  silver  are  also  employed  in  the  neighborhood 
of  the  affected  nerve;  their  effects  are  nil  or  only  of  short  duration.  In 
the  majority  of  cases,  hypodermic  injections  of  morphine  constitute  a 
useful  palliative  measure.  They  promptly  relieve  the  violence  of  the 
pains  and  may  be  repeated  two  or  three  times  daily  for  months  without 
the  disturbances  of  digestion,  which  are  almost  always  produced  by  the 
internal  administration  of  opium  in  large  doses.  But,  after  a  certain 
length  of  time,  the  subcutaneous  injections  also  lose  their  efficacy.  I 
have  seen  two  cases  of  frontal  and  supraorbital  neuralgia,  lasting  for 
several  months,  which  yielded  after  the  use  of  subcutaneous  injections  of 
morphine  for  a  few  weeks.  The  disease  has  not  reappeared  at  the  end 
of  two  years. 

Among  the   newer  remedies,    electricity  and    hydrotherapeutics   are 


212  CLINICAL    TEEATISE    ON 

most  frequently  employed.  The  induced  current  must  be  applied  with 
caution,  on  account  of  its  great  tension;  the  painful  points  are  touched 
with  an  electrode  in  the  form  of  a  brush,  until  a  slight  erythema  appears, 
la  using  the  less  irritating  constant  current,  the  anode  is  applied  over 
the  cervical  vertebrae  or  under  the  mastoid  processes,  and  the  thinner 
cathode  is  placed  over  the  inincta  dolorosa  (with  an  increasing  cfirrent). 
The  influence  of  the  galvanic  current  upon  the  circulatory  and  trophic 
phenomena  is  sometimes  successful  even  in  inveterate  forms,  as  I  have 
observed  in  several  cases  and  as  has  been  confirmed  by  Niemeyer,  Wies- 
ner,  etc.  In  the  majority  of  cases,  we  at  least  obtain  some  improve- 
ment; the  attacks  become  less  frequent  and  intense  and,  if  a  relapse  oc- 
curs, the  patients  demand  a  renewal  of  the  treatment.  But,  in  certain 
chronic  forms,  electrical  treatment  fails  completely.  Hydrotherapeutic 
measures  (daily  moist  packs  from  fifteen  to  thirty  minutes'  duration,  fol- 
lowed by  cool  half  baths  with  affusions)  have  often  furnished  good  re- 
sults in  relieving  the  morbid  excitability  of  the  nerves  of  the  face.  But 
irritant  measures  (cold-water  douches,  etc.)  should  be  completely  pro- 
scribed. 

If  all  these  methods  of  treatment  have  failed,  surgical  interference 
constitutes  the  only  means  left  at  our  command.  The  uselessness  of  sim- 
ple neurotomy  has  caused  it  to  be  almost  entirely  abandoned.  At  pres- 
ent, the  only  operation  resorted  to  is  excision  of  the  nerves  (neurectomy), 
and  the  portion  removed  should  measure,  according  to  Bruns,  at  least  a 
centimetre  in  length.  As  trigeminal  neuralgia  generally  invoh"es  the 
second  branch,  this  nerve  is  most  frequently  operated  upon,  and  in  order 
to  approach  the  source  of  the  neuralgia,  the  nerve  is  often  excised  at  its 
exit  from  the  foramen  rotundum,  with  the  object  of  separating  its  branches 
from  all  communication  with  the  brain. 

According  to  Bruns,  the  operation  is  indicated  when  the  pain  occu- 
pies a  fixed  position  and  a  small  extent  of  surface;  when  the  paroxj'sms 
are  provoked  by  external  causes  acting  upon  the  peripheral  terminations 
of  the  nerves;  in  those  cases  in  which  the  cause  of  the  disease  is  situated 
at  a  point  beyond  which  the  nerve  is  accessible  to  the  bistoury;  in  cases 
attended  with  intolerable  pains,  which  threaten  to  destroy  the  vital  ener- 
gies of  the  patient.  The  possibility  of  relapse  should  not  militate  against 
resection. 

Although  its  curative  action  may  only  extend  over  a  period  varying 
from  a  few  months  to  two  or  three  years,  the  resection  prolongs  life  for 
several  years  without  presenting,  in  the  majority  of  eases,  any  serious 
dangers. 

According  to  the  latest  statistics  of  Bruns  and  A.  Wagner,  among 
one  hundred  and  thirty-five  cases  of  neurectomy,  the  operation  failed  nine 
times;  death  occurred  in  six  cases,  relapses  at  the  end  of  several  months 
thirty-two  times,  at  the  end  of  several  years  (up  to  the  third  year)  twenty 
times;  no  relapse  at  the  end  of  several  months  eighteen  times,  at  the  end 
of  several  years  twenty-three  times;  the  duration  of  recovery  was  not 
mentioned  in  twenty -four  cases. 

We  may  finally  mention  ligature  of  the  carotid,  the  impetus  to  the 
performance  of  this  operation  being  due  to  the  diminution  of  the  pains 
observed  upon  compression  of  the  carotid.  It  was  proposed  by  Nussbaum 
and  performed  successfully  eleven  times.  Patruban  had  six  recoveries 
among  seven  cases,  one  case  terminating  fatally.  Further  surgical  ob- 
servations are  necessary  in  order  to  enable  us  to  determine  the  value  of 
ligature  of  the  carotid  as  a  radical  operation. 


DISEASES    OF   THE    NERVOUS    SYSTEM.  213 


2.    SPASMS   OF   THE   TEIGEMINUS. 

After  having  considered  the  phenomena  of  morbid  irritation  in  the 
sensory  portions  of  the  fifth  pair,  it  remains  for  us  to  discuss  those  which 
affect  the  motor  portion  of  the  trigeminus.  They  are  known  as  masseteric 
spasm,  or  tonic  or  clonic  spasm  of  the  masseter. 

Tonic  spasm  of  the  elevators  of  the  lower  jaw  (temporal  and  masseter) 
constitutes  trismus,  of  which  we  have  previously  spoken;  clonic  spasm 
alternating  between  these  two  muscles  and  the  depressors  of  the  lower 
jaw  (amterior  belly  of  the  digastric  and  mylo-hyoid)  constitutes  the  chat- 
tering of  the  teeth  in  fever;  I  have  also  seen  these  spasms  of  the  jaw  in 
hysteria,  combined  with  other  clonic  spasms. 

Tonic  spasm  of  the  depressors  of  the  lower  jaw  is  rarer  and  is  mani- 
ifested  by  the  mouth  being  continually  kept  open  (divaricatio  maxillae 
inf.).  Tonic  spasm  of  the  lateral  muscles  of  the  jaw  (external  and  inter- 
nal pterygoids)  produces  an  automatic  movement  of  the  maxilla  and  grind- 
ing of  the  teeth.  Leube  reports  a  case  (Arch.  f.  Klin.  Med.,  I.  Bd.)  of 
tonic  spasm  of  these  muscles  in  an  hysterical  patient;  the  contraction  of 
the  right  pterygoids  carried  the  lower  jaw  to  the  left,  and  the  lower  teeth 
passed  in  front  of  the  upper.  The  case  recovered  in  three  days  by  the 
employment  of  the  induced  current  and  the  internal  administration  of  ar- 
senic. 

The  causes  of  these  spasms  may  be  central,  such  as  apoplexy,  cerebral 
softening,  meningitis,  localized  affections  of  the  pons  or  medulla  oblon- 
gata, hysteria,  epilepsy,  tetanus,  and  hydrophobia,  or  they  may  be  of 
peripheral  origin,  following  exposure,  basilar  meningitis,  or  tumors  irrita- 
ting the  motor  portion  of  the  Gasserian  ganglion.  The  spasms  are  some- 
times of  a  reflex  nature  and  may  be  produced  by  dental  pains,  teething, 
and  intestinal  or  uterine  irritation.  By  careful  examination,  we  will 
avoid  mistaking  trismus  for  inflammation  or  ankylosis  of  the  temporo- 
maxillary  joint.  In  rheumatic  trismus,  the  excessive  reflex  excitability 
peculiar  to  tetanus  is  wanting.  Trismus  and  tetanus  of  the  new-born 
have  been  discussed  on  page  92,  Vol.  II. 

The  prognosis  is  favorable  when  the  spasms  are  of  peripheral  origin, 
but  doubtful  in  the  central  forms. 

The  treatment  of  spasms  of  the  jaw  in  the  central  forms  must  be  anti- 
phlogistic and  derivative;  in  the  reflex  varieties,  we  should  endeavor  to 
remove  the  cause  of  irritation.  Subcutaneous  injections  of  morphine  or 
atropine  and  enemata  of  laudanum  or  chloroform,  sometimes  prove  suc- 
cessful. In  rheumatic  trismus,  recourse  may  be  had  to  vapor  baths,  to 
the  application  of  progressive  increasing  faradic  currents  to  the  muscles, 
or  to  stabile  galvanic  currents. 


3.   TEIGEMIXAL   PARALYSIS. 

The  motor  and  sensory  portions  of  the  trigeminus  may  be  separately 
affected  with  paralysis;  they  are  rarely  affected  at  the  same  time.  Tri- 
geminal anaesthesia,  as  we  have  shown  above,  may  be  of  central  origin,  as 
in  apoplexy,  ataxia,  hysteria,  and  in  the  diseases  involving  the  large  root 
of  the  fifth  pair  between  the  pons  and  olivary  bodies.  We  have  discussed 
these  conditions  with  the  necessary  detail  in  preceding  chapters. 

At  the  present  time,  we  have  special  reference  to  peripheral  an^esthe- 


214  CLIN'ICAL    TREATISE    ON 

sia,  which  may  be  caused  by  disturbances  of  conduction  or  by  abolition 
of  the  local  irritability  of  the  trigeminus.  The  causes  of  this  affection 
are  as  follows:  exposure,  traumatism,  surgical  operations,  caries  of  the 
osseous  canals,  suppuration  of  the  soft  parts,  tumors  or  exudations  at  the 
base  of  the  brain;  it  also  exists  in  the  Norwegian  leprosy,  described  by 
Daniellsen  and  Boeck,  and  in  which  sclerosis  of  the  peripheral  nerves 
has  been  found. 

The  anaesthesia  may  be  complete  and  attended  with  abolition  of  sen- 
sibility to  contact,  pain,  and  temperature  ;  or  it  may  be  incomplete, 
strong  impressions  are  still  perceived,  or  some  forms  of  sensibility  may  be 
diflferentiated.  As  each  portion  of  the  integument  of  the  face  is  applied 
by  the  nerve  filaments  of  different  branches,  a  careful  examination  of  the 
patient  requires  the  use  of  a  needle,  compass,  or  electrical  brush. 

Paralysis  of  the  first  branch  gives  rise  to  contraction  of  the  pupil,  in- 
sensibility of  the  conjunctiva,  upper  lid  and  integument  of  the  forehead, 
a  diminution  in  the  sensibility  of  the  skin  of  the  inferior  and  external 
parts  of  the  nose,  and  an  abolition  of  the  tactile  sense  in  the  anterior 
portion  of  the  nasal  mucous  membrane. 

Paralysis  of  the  second  branch  causes  a  disappearance  of  sensibility  in 
the  lower  lid,  in  the  corresponding  portions  of  the  cheek  and  nose,  in  half 
of  the  upper  lip,  in  the  middle  and  posterior  regions  of  the  nasal  mucous 
membrane,  in  the  mucous  membrane  of  the  roof  of  the  palate,  velum 
palati,  uvula,  and  in  the  teeth  and  gums  of  the  upper  jaw. 

In  paralysis  of  the  third  branch,  there  is  loss  of  cutaneous  sensibility 
in  front  of  the  temporo-maxillary  articulation,  upon  the  outer  surface  of  the 
ear,  in  the  temporal  region,  in  a  portion  of  the  external  auditory  meatus, 
in  half  of  the  lower  lip  (internally  and  externally),  in  the  tongue,  buccal 
mucous  membrane,  tonsils,  teeth  and  gums  of  the  lower  jaw.  In  lesions 
of  small  nerre  filaments,  the  paralysis  only  affects  the  corresponding 
cutaneous  surface. 

Patients  affected  by  anaesthesia  are  very  much  exposed  to  wounds,  in- 
flammations and  abscesses  of  the  peripheral  parts.  The  gums  are  hypen^jmic 
and  ulcerated,  bleed  readily,  and  may  even  gangrene  in  certain  places, 
under  the  influence  of  unfavorable  causes.  In  rabbits,  in  whom  the  trige- 
minus has  been  cut  within  the  cranial  cavity,  ulcerations  readily  occur 
upon  the  nose,  lips,  palate,  and  sometimes  upon  the  tongue,  which  pre- 
sents white  spots,  or  upon  other  parts  exposed  to  pressure. 

The  most  characteristic  and  serious  symptoms  are  the  disturbances  in 
the  nutrition  of  the  eye,  which  Magendie  (Journ.  de  physiol.  experiment., 
t.  IV.,  1824)  first  observed  after  destruction  of  the  trigeminus  (within  the 
skull)  in  rabbits.  The  symptoms  previously  mentioned  were  followed,  at 
the  end  of  eight  days,  by  redness  of  the  conjunctiva  and  iris,  by  cloudi- 
ness, discoloration  and  central  ulceration  of  the  cornea,  and  then  by 
rupture  and  atrophy  of  the  eye.  The  first  observations  of  this  character 
in  man  were  published  by  Landmann  and  Charles  Bell,  and  since  then 
various  other  cases  of  purulent  destruction  of  the  eye,  especially  in  tumors 
compressing  the  trigeminus  in  the  vicinity  of  the  Gasserian  ganglion,  have 
been  reported.  I  have  referred  to  two  personal  cases  on  p.  118  (with 
anaesthesia  dolorosa)  and  p.  127. 

The  later  researches  of  Snellen  (Arch.  f.  hollaend.  Beitr.  z.  Nat.  u. 
Heilk.,  1858)  seemed  to  show  that  ocular  suppuration  is  merely  the  result 
of  mechanical  lesions,  the  anjesthetic  conjunctiva  being  deprived  of  its  re- 
flexes and  its  role  as  protector.  In  recent  observations  by  Baerwinkel 
(Arch.  f.  klin.  Med.,  XII.  Bd.,  1874)  and  Spencer  Watson  (Med.  Times, 


DISEASES    OF   THE    NERVOUS    SYSTEM.  215 

1874),  in  patients  presenting  tumor  symptoms,  ulceration  of  the  cornea 
was  cured  by  artificial  closure  of  the  lids,  without  any  change  occurring  in 
the  facial  paralysis  and  anesthesia. 

Other  observations  prove  that  the  disturbances  of  ocular  nutrition  are 
not  dependent  upon  anaesthesia.  Bock  (Mueller's  Arch.,  1844)  and  Fried- 
reich (Beitr.  z,  Lehre  v.  den  Schaedelgeschw.,  1853)  have  seen  cases  in 
which  ophthalmia  developed  (in  patients  suffering  from  tumor)  despite 
the  preservation  of  sensibility.  We  may  also  refer  to  the  experiment 
performed  by  Samuel  (Die  trophischen  Nerven,  1860,  p.  Gl)  who,  after 
having  produced  a  violent  irritation  of  the  Gasserian  ganglion  in  rabbits 
by  means  of  the  induced  current,  observed  the  development  of  acute 
ophthalmia,  accompanied  by  hypera?sthesia  of  the  eye. 

Meissner  has  deduced  from  his  experiments  (Zschr.  f.  rat.  Med.,  XXIX. 
Bd.)  a  different  interpretation  of  the  symptoms  following  section  of  the 
trigeminus.  In  animals  in  whom  the  eye  remained  sensitive  but  had 
nevertheless  become  inflamed,  the  nerve  was  wounded  in  its  median  por- 
tion. In  three  other  cases  of  incomplete  neurotomy,  in  which  the  most 
internal  fibres  had  escaped,  the  eye  was  insensible,  but,  although  exposed, 
did  not  become  the  seat  of  nutritive  disturbances.  Neuro-paralytic  ocu- 
lar inflammations  are  therefore  due  to  section  of  the  trophic  fibres  contained 
in  the  central  portion  of  the  nerve.  This  view  is  confirmed  by  Schiff's 
experiments  (Centralbl.,  18G7)  upon  lesions  of  the  trigeminus  with  pre- 
servation of  sensibility.  Sinitzin  has  more  recently  undertaken  some 
extremely  interesting  experiments  (Med.  Centralbl.,  II.,  1871).  He  ob- 
served that  extirpation  of  the  upper  cervical  ganglion  of  the  sympathetic 
system  caused  the  disappearance  of  trigeminal  ophthalmia  if  the  latter 
were  not  too  far  advanced.  If  the  extirpation  of  the  ganglion  was  per- 
formed previous  to  section  of  the  trigeminus,  the  ocular  inflammation  was 
not  produced.  After  section  of  the  sympathetic,  the  eye  upon  the 
operated  side  acquired  a  greater  resistance  to  external  irritation;  the  in- 
troduction of  small  bits  of  glass  produced  less  serious  disorders  than  upon 
the  sound  side,  in  which  the  eye  became  readily  inflamed.  After  excision 
of  the  upper  cervical  ganglion,  there  was  an  increased  supply  of  blood  to 
the  eye,  visible  to  the  ophthalmoscope,  and  the  temperature  became  ele- 
vated. 

A  great  diversity  of  opinions  has  resulted  from  these  numerous  experi- 
ments. AVhile  some  authors  attribute  the  ophthalmia  to  traumatic  irita- 
tion,  others  regard  it  as  chiefly  due  to  the  trophic  fibres  of  the  fifth  pair, 
which  originate  in  the  Gasserian  ganglion.  Finally,  according  to  Charcot 
and  Friedreich,  the  trophic  disturbances  in  the  eye  are  caused  by  an 
inflammatory  irritation  (descending  neuritis).  In  an  experiment  performed 
by  Buettner,  after  multiple  incisions  into  the  Gasserian  ganglion  and  a 
purulent  ophthalmia  of  rapid  course  (despite  the  immediate  application 
of  a  protecting  apparatus),  the  ganglion  was  found  in  a  condition  of  trau- 
matic inflammation,  extending  into^he  ophthalmic  branch.  According  to 
the  recent  experiments  by  Feuer  (Wien.  Med.  Jahrb.,  t.  II.,  1877),  kera- 
titis after  section  of  the  trigeminus  is  due  to  the  cessation  of  the  move- 
ments of  the  lids;  the  portion  of  the  cornea  situated  in  the  fissure  of  the 
lids  first  becomes  necrotic,  and  this  source  of  irritation  causes  a  reactive 
inflammation  of  the  surrounding  tissues,  in  order  to  eliminate  the  necrosed 
part.  The  artificial  protection  of  the  operated  eye  prevents  the  develop- 
ment of  keratitis.  We  still  require  a  careful  study  of  experimental  data 
and  of  human  pathology  in  order  to  decide  this  question  definitely. 

In  forming  a  diagnosis  we  must  endeavor  to  distinguish  the  central  or 


216  CLINICAL   TREATISE    ON 

peripheral  origin  of  the  trigeminal  anaesthesia.  In  the  central  forms,  the 
third  branch  is  usually  alone  affected;  we  must  also  pay  attention,  in  addi- 
tion to  the  previous  history,  and  to  the  co-existence  of  paresis  or  paral- 
ysis, of  the  face,  tongue  jaws,  or  limbs.  Anaesthesia  from  tumors  at  the 
base  of  the  brain  are  characterized  by  cephalic  symptoms,  the  simulta- 
neous affection  of  adjacent  cranial  nerves,  the  frequent  transformation  of 
facial  neuralgia  into  anaesthesia,  the  electrical  reactions  of  the  facial  paral- 
ysis, and  the  previously  mentioned  trophic  disturbances.  The  previous 
existence  of  periostitis,  abscess,  local  tumefaction,  and  pain,  enable  us  to 
attribute  the  antesthesia  to  periostitis  or  caries  of  the  osseous  canals. 
Syphilitic,  traumatic,  or  rheumatic  agencies  are  readily  recognized  in  in- 
dividuals who  are  otherwise  healthy. 

With  the  exception  of  anaesthesia  due  to  the  latter  affections,  the  prog- 
nosis is  usually  unfavorable,  because  we  are  incapable  of  reaching  the 
cause  of  the  disease.  Anaesthesia  of  long  duration  is  almost  always  ac- 
companied by  persistent  changes  in  the  texture  of  the  nerves. 

In  trigeminal  anaethesia  of  central  origin  we  can  expect  little  good 
from  treatment.  Surgical  interference  may  be  resorted  to  in  accessible 
tumors  or  foreign  bodies.  Iodide  of  potassium  is  indicated  if  periostitis 
is  present.  When  the  disease  is  of  peripheral  origin,  we  may  prescribe 
frictions  with  volatile  substances,  cutaneous  revulsives,  and  cold  douches 
to  the  face;  one  of  the  most  efficient  measures  of  treatment  consists  of  the 
electrical  brush  with  a  progressively  increasing  secondary  current. 

In  a  case  of  S3'philitic  anesthesia  of  the  posterior  half  of  the  cheek, 
(with  circumscribed  necrosis  of  the  maxilla  and  vault  of  the  palate),  I 
obtained  recovery  by  the  use  of  iodide  of  potassium,  followed  by  faradi- 
zation. 

Motor  paralysis  of  the  small  root  of  the  trigeminus  produces  paralysis 
of  the  muscles  of  the  jaw,  with  the  exception  of  the  buccinator,  which  is 
innervated  by  the  facial.  In  paralysis  of  the  masticators,  the  healthy  mus- 
cles push  the  jaw  to  the  opposite  side  during  mastication.  The  cause  of 
this  paralysis  is  frequently  central  (meningitis,  extravasations,  tumors); 
morbid  pi'ocesses  at  the  base  of  the  brain  may  at  first  affect  the  sensory 
and  then  the  motor  portion  of  the  trigeminus,  and  in  these  cases  we  find 
other  symptoms  peculiar  to  basilar  affections.  The  prognosis  is  usually 
unfavorable.  Electrical  treatment  (faradization  of  the  muscles  of  the  jaw) 
may  perhaps  produce  improvement  in  some  cases. 


b.  Diseases  of  the  Pnewnxogastric  Nerve. 

Despite  the  anastomoses  which  establish  intimate  relations  between 
the  pneumogastric  and  spinal  accessory  nerves,  and  thus  prevent  us  from 
obtaining  a  precise  knowledge  of  the  functions  of  each,  we  shall,  never- 
theless, endeavor  from  a  clinical  standpoint  to  trace  separately,  as  far  as 
possible,  the  physiological  and  pathological  history  of  these  two  nerves. 
We  shall  begin  with  the  affections  of  the  pneumogastric,  which,  with 
Volkmann,  Hyrtl  and  Valentin,  we  regard  as  a  mixed  nerve,  as  its  motor 
branches  are  too  numerous  to  be  derived  from  its  slight  anastomoses  with 
the  spinal  accessory. 

The  pharyngeal  branch  of  the  pneumogastric  is  both  motor  and  sen- 
sory. Irritation  of  the  vagus  at  its  exit  from  the  jugular  foramen  pro- 
duces contractions  of  the  pharynx  and  oesophagus;  in  favorable  cases, 
contractions  are  also  noticed  in  certain  muscles  of  the  velum  palati  (Val- 


DISEASES    OP   THE    NERVOUS    SYSTEM.  217 

entin).  As  an  irritative  phenomenon  in  the  course  of  the  pharyngeal 
nerves,  we  may  mention  the  globus  hystericus,  which  is  not  usually  of  a 
spasmodic  nature,  since  it  does  not  prevent  the  patients  from  swallowing. 
In  paralysis  of  the  pharyngeal  branches  of  the  pneumogastric,  deglutition 
is  very  much  embarrassed  and  becomes  almost  impossible  when  the  affec- 
tion is  bilateral. 

The  superior  laryngeal  nerve  is  extremely  sensitive.  Irritation  of  the  central  por- 
tion and  especially  of  its  inner  branch,  produces,  according  to  J.  Rosenthal  (Die  Ath- 
embewegungen  und  ihre  Beziehungen  zum  Vagus,  Berlin,  18G2)  an  arrest  of  inspiration 
and  contraction  of  the  expiratory  muscles,  with  simultaneous  relaxation  of  the  dia- 
phragm. The  internal  branch  presides  over  the  reflex  movements  of  cough,  when  a 
foreign  body  irritates  the  laryngeal  mucous  membrane.  Irritation  of  the  superior 
laryngeal  nerve  also  gives  rise  to  cough.  Section  of  both  superior  laryngeal  nerves 
causes  slo^ving  of  the  respiratory  rhythm  ;  and,  since  paralysis  of  the  crico-thyroid 
arrests  the  rotatory  movements  of  the  cricoid  cartilage  and  diminishes  the  tension  of 
the  vocal  cords,  the  voice  of  the  animal  becomes  very  hoarse. 

The  superior  laryngeal  nerve  is  subject  to  peculiar  conditions  of  irrita- 
tion, although  it  is  rarely  paralyzed.  Among  the  former,  we  may  mention 
spasm  of  the  glottis  and  whooping-cough.  Spasm  of  the  glottis  (stridu- 
lous  laryngitis,  Kopp's  asthma)  is  an  asphyxial  disorder  peculiar  to  child- 
hood, occurring  almost  always  at  night  in  children  otherwise  perfectly 
healthy,  and  attended  with  pallor  or  turgidity  of  the  face,  retraction 
of  the  head,  and  sibilant  inspiration  which  is  often  terminated  by  a 
cry.  General  eclamptic  spasms  frequently  occur  after  the  paroxysms. 
The  first  three  years  of  life,  infantile  rickets,  antemia  and  the  digestive 
disorders  which  accompany  it,  are  the  factors  which  furnish  the  greatest 
contingent  to  this  disease.  It  is  much  more  frequent  in  winter  than  in 
summer.  It  is  sometimes  observed  in  adults  after  exposure,  and  in  hys- 
teria. 

Stridulous  laryngitis  is  supposed  to  be  due  to  a  spasm  of  the  constric- 
tors of  the  glottis,  although  this  has  not  been  directly  observed  during  an 
attack,  by  means  of  the  laryngoscope.  The  disease  is  usually  chronic,  but 
possesses  no  gravity;  death  from  asphyxia  is  a  rare  termination.  Treat- 
ment: During  the  attack,  cold  injections,  inhalations  of  ether  or  chloro- 
form, drawing  the  base  of  the  tongue  upwards  and  forwards  with  the  finger, 
and  raising  the  epiglottis  (Krahner)  are  indicated.  In  the  intervals  of 
the  attacks,  employ  moist  frictions,  bromide  of  potassium  (in  large  doses), 
and  tonic  preparations. 

Whooping-cough  (tussis  convulsiva)  and  the  spasmodic  cough  of  hys- 
teri|L  are  also  included  in  this  category.  They  consist  of  spasmodic  con- 
vulsions of  the  expiratory  muscles,  with  spasm  of  the  glottis  and  inter- 
mittent suspension  of  inspiration.  According  to  Rosenthal's  experiments 
(I.  c),  irritation  of  the  superior  laryngeal  nerve  produces  analogous 
symptoms.  The  contagious,  catarrhal  secretion  of  whooping-cough  pro- 
duces an  increasing  irritation  of  the  nerve-fibres  in  the  laryngeal  mucous 
membrane,  attended  with  the  characteristic  paroxysms.  In  the  hysterical 
forms,  the  irritation  undoubtedly  starts  from  the  spinal  centre.  Treat- 
ment: The  most  efficient  remedies  consist  of  belladonna,  bromide  of  po- 
tassium, inhalations  of  chloroform,  the  use  of  a  spray  of  tincture  of  hy- 
oscyamus  or  belladonna,  and  of  nitrate  of  silver. 

The  recurrent  nerve  is  the  true  nerve  of  phonation,  for,  with  the  ex- 
ception of  the  crico-thyroid,  it  innervates  all  the  other  laryngeal  muscles. 
Section  of  both  inferior  laryngeal  branches  causes  paralysis  of  the  dilators 
of  the  glottis  and  the  tensors  of  the  vocal  cords.     In  this  condition,  the 


218  CLINICAL    TREATISE    ON 

inspired  air  may  cause,  in  young  animals,  collapse  of  the  walls  of  the 
glottis  and  asphyxia,  while,  during  repose,  adult  animals,  who  possess  a 
larger  glottis,  may  compensate  for  the  diminution  of  the  air  supply  by 
more  frequent  respiration.  In  forced  respiration,  however,  the  relaxed 
vocal  cords  become  applied  to  one  another  and  give  rise  to  asphyxial 
phenomena. 

In  man,  the  paralyses  of  the  vocal  cord  have  only  been  thoroughly 
uuderstood  since  the  introduction  of  the  laryngoscope.  The  primary 
central  causes  of  paralysis  of  the  recurrent  nerve  include  the  following  : 
apoplexy,  cerebral  tumors,  multiple  paralyses  of  the  cranial  nerves,  hys- 
teria, diphtheria,  typhoid  fever,  and  diseases  of  the  genital  apparatus. 
The  peripheral  causes  include  :  inflammations,  traumatism,  cancer,  sar- 
coma, tumors  of  the  lymphatic  glands,  goitre,  aneurism  of  the  aorta, 
innominata  and  subclavian  arteries,  pericardial  exudations,  lesions  of 
the  larynx  or  oesophagus,  pulmonary  tuberculosis  or  induration.  Atrophy 
of  the  recurrent  nerve  and  atrophy  and  fatty  degeneration  of  the  para- 
lyzed muscles  have  been  observed  upon  autopsy. 

Paralysis  of  the  recurrent  nerve  may  be  complete  or  incomplete,  uni- 
lateral or  bilateral.  In  complete  double  paralysis,  the  laryngoscope  dis- 
closes, according  to  Ziemssen,  the  following  appearances  :  cadaveric 
relaxation  of  both  vocal  cords  and  of  the  arytenoid  cartilages,  absolute 
aphonia,  expulsion  of  an  enormous  quantity  of  air  when  the  patient 
wishes  to  speak  or  cough.  There  is  inability  to  cough  strongly  and  to 
expectorate,  but  no  dyspnoea  in  adults,  except  after  exertion.  When  the 
paralysis  is  incomplete  or  unequal  on  both  sides,  the  appearances  are 
analogous,  but  the  movements  of  the  vocal  cords  and  phonation  are  still 
possible  to  a  slight  extent. 

In  forming  a  dlagiiosls,  we  can  frequently  determine  the  nature  of 
the  paralysis,  by  ascertaining  its  cause.  But,  in  certain  cases  it  is  im- 
possible to  determine  whether  the  paralysis  is  traumatic,  rheumatic, 
neuropathic,  or  myopathic.  The  prognosis  varies  according  to  the  nature 
of  the  case,  and  in  great  part  also  according  to  the  integrity  or  abolition 
of  the  excitability  of  the  paralyzed  muscles  and  nerves  to  both  currents. 

With  regard  to  treatment,  the  early  employment  of  the  electrical 
current  furnishes  the  best  results,  but  this  is  not  true  of  all  hysterical 
paralyses.  Faradization  of  the  larynx  is  practised  through  the  skin  by 
means  of  secondary  currents  of  increasing  intensity,  or  an  electrode  of 
the  proper  shape  is  introduced  into  the  interior  of  the  larynx,  by  the  aid 
of  a  mirror,  while  the  other  pole,  applied  to  the  thyroid  cartilage,  is  con- 
nected with  an  induced  or  galvanic  current  of  moderate  intensity.  Gal- 
vanization of  the  inferior  laryngeal  nerve  may  also  be  practised  by  firmly 
pressing  a  thin  electrode  into  the  groove  which  separates  the  trachea  from 
the  oesophagus. 

The  pulmonary  plexus  of  the  vagus,  formed  by  the  bronchial  nerves 
and  the  branches  of  the  sympathetic,  may  cause  (either  from  irritation  of 
the  pneumogastric  or  by  reflex  means)  a  spasm  of  the  bronchial  muscles, 
a  result  which  is  also  obtained  experimentally  after  irritation  of  the 
vagus  or  of  the  mucous  membrane.  The  older  authors  termed  this  affec- 
tion nervous  asthma.  It  may  be  produced  by  a  mental  influence  acting 
upon  the  cerebral  origin  of  the  pneumogastric,  by  tumors  compressing  the 
trunk  of  the  nerve,  by  reflex  means  as  in  hysteria  (uterine  asthma),  by 
exposure,  and  by  the  inhalation  of  irritating  powders  (very  small  quanti- 
ties of  ipecacuanha  in  nervous  females).  Bronchial  asthma  occurs  in 
paroxysms  separated  by  longer  or  shorter  intervals. 


DISEASES    OP   THE    NERVOUS    SYSTEM.  219 

The  attack  often  begins  at  night ;  the  patient,  wakened  by  a  feeling  of  oppression, 
is  compelled  to  sit  up  in  bed  and  the  respiration  becomes  sibilant  and  noisy.  The 
patient  becomes  terrified,  the  face  is  pale,  the  forehead  covered  with  a  cold  sweat,  the 
head  thrown  backwards,  the  arms  are  fixed  and  all  the  inspiratory  muscles  act  con- 
vulsively in  order  to  raise  the  thoracic  walls.  The  cardiac  impulse  is  violent  and 
irregular,  the  pulse  small  and  feeble,  the  temperature  lowered.  This  condition  lasts 
fi.fteen  minutes  (rarely  longer).  Sometimes,  when  the  respiratory  passages  are  again 
free,  the  air  penetrates  violently  and  noisily,  or  the  dyspnoea  may  cease  gradually 
with  the  expectoration  of  a  thick,  frothy  mucus. 

The  prognosis  is  not  unfavorable,  especially  in  recent  cases,  and  even 
in  chronic  forms  life  is  rarely  endangered. 

The  treatment,  during  the  paroxysms,  consists  in  energetic  friction 
of  the  chest  and  lower  limbs,  the  admission  of  plenty  of  fresh  air,  and 
the  application  of  cutaneous  revulsives.  The  patient  should  take  small 
mouthfuls  of  strong  coffee,  tea  or  ice  (Romberg).  Subcutaneous  injec- 
tions of  morphine,  inhalations  of  chloroform,  and  emetics  are  only  indi- 
cated in  grave  cases.  During  the  periods  of  rem.ission,  we  may  prescribe 
with  advantage  the  continuous  use  of  belladonna,  Fowler's  solution,  or 
iodide  of  potassium.  I  have  also  obtained  good  effects  from  the  method- 
ical employment  of  compressed  air,  from  change  of  air,  and  especially 
from  prolonged  residence  in  southern  climates  and  in  a  marine  atmos- 
phere. In  young  and  nervous  people  or  in  hysterical  patients,  the  best 
treatment  is  the  adoption  of  moist  frictions  over  the  entire  body  (the 
water  should  not  be  too  cold)  during  the  intervals  between  the  parox- 
ysms. Even  in  inveterate  forms,  the  attacks  disappear  or  become  more 
infrequent  and  milder  under  this  plan  of  treatment. 

Among  the  paralytic  symptoms  affecting  the  pulmonary  function  of 
the  vagus,  we  must  first  mention  the  neuroparalytic  hypertemia  and  its 
sequences,  due  to  section  of  the  nerve.  As  the  vascular  nerves  of  the 
lung  enter  the  organ  with  the  trunk  of  the  pneumogastric,  a  lesion  of  this 
nerve  produces  dilatation  of  the  pulmonary  vessels  and  a  serous  infiltra- 
tion into  the  parenchyma.  Valentin  has  observed  a  phenomenon  which 
proves  that  this  hypertemia  is  not  of  mechanical  origin.  During  the  hy- 
bernating  period,  marmots  do  not  swallow  or  secrete  any  buccal  fluid,  and 
their  respiration  is  not  markedly  changed.  Section  of  the  vagus  will  nev- 
ertheless produce  in  them  pulmonary  congestion.  Similar  disturbances 
in  the  lungs  may  be  caused  by  surgical  lesions,  compression  of  the  nerve 
by  tubercular  or  cancerous  degenerations  of  the  glands  (especially  those 
which  are  situated  at  the  bifurcation  of  the  bronchi),  aneurisms  of  the 
thoracic  vessels,  etc. 

Arrest  of  the  heart's  action  is  caused  much  more  rarely  by  irritation 
than  by  paralj^sis  of  the  pneumogastric.  Czermak  experimented  upon  him- 
self (Prag.  Vjschr.,  1868)  by  producing  prolonged  digital  compression  of 
the  right  pneumogastric,  and  thus  caused  arrest  of  the  heart's  action  with 
a  feeling  of  oppression.  In  a  case  observed  at  Skoda's  clinic  and  pub- 
lished by  Heine  (Mueller's  Arch.  f.  Physiol.,  1841),  the  symptoms  were 
those  of  angina  pectoris.  At  the  autopsy,  Rokitansky  found  the  cardiac 
plexus  thickened  and  surrounded  by  a  black  tumor  as  large  as  a  hazel- 
nut; lower  down,  the  fibres  of  the  left  pneumogastric  going  to  the  pul- 
monary plexus  were  also  compressed  by  a  bluish-black,  hypertrophied 
lymphatic  gland.  More  recently,  Concato  and  Rossbach  have  also  ob- 
served retardation  and  an  unrhythmical  condition  of  the  pulse  from  com- 
pression of  the  pneumogastric  nerve. 

Angina  pectoris  (cardiac  neuralgia)  is  a  neurosis  of  the  heart,  occur- 


220  CLimCAL    TREATISE    OTT 

ring  paroxysmally  and  accompanied  by  radiating  pains  into  the  neck  or 
arm,  and  is  attributed  either  to  a  hyperfesthesia  of  the  cardiac  plexus  or 
to  motor  disorders  of  the  cardiac  nerves.  The  disease  almost  always  be- 
gins suddenly  by  a  painful  constriction  of  the  chest,  with  a  distressing 
sense  of  exhaustion,  which  is  of  very  short  duration.  Angina  pectoris 
may  accompany  various  cardiac  affections  (hypertrophy,  fatty  degenera- 
tion, lesions  of  the  aortic  valves,  ossification  of  the  coronary  arteries)  or 
may  follow  excitement  or  depressing  emotions.  The  proffnosis  is  very 
bad.  The  treatment  during  the  attack  consists  of  the  careful  administra- 
tion of  ether  by  inhalations,  and  of  small  doses  of  opium.  During  the 
intervals,  quinine  and  increasing  doses  of  Fowler's  solution  may  be  admin- 
istered. 

Ludwig  and  Cyon  have  discovered  the  depressor  nerve  (Saechs.  akad. 
Berichte,  1868),  a  sensory  cardiac  branch  of  the  pneumogastric,  the  cen- 
tral irritation  of  which  diminishes  vascular  tonus.  We  are  too  little  ac- 
quainted with  the  functions  of  this  nerve  in  man  to  study  its  pathological 
history  with  any  degree  of  success. 

In  conclusion,  we  will  examine  the  disorders  of  the  abdominal  portion 
of  the  pneumogastrics.  This  category  includes  nervous  cardialgia,  bouli- 
mia,  polydipsia,  nervous  vomiting,  and  paralysis  of  the  functions  of  the 
stomach.  Cardialgia  (gastrodynia)  is  a  neuralgia  of  the  sensory  fibres  of 
the  stomach,  manifesting  itself  by  periodical  attacks  attended  with  a 
constricting  pain  in  the  pit  of  the  stomach  and  with  irradiations  into  the 
back  and  thorax.  As  the  pain  increases,  the  patient  groans  and  Avrithes 
and  is  obliged  to  lie  down.  There  is  reflex  irritation  of  the  vascular  and 
cardiac  nerves,  pallor  of  the  face,  coldness  of  the  limbs,  small,  irregular 
pulse,  and  usually  retraction  of  the  epigastric  region.  The  attacks  last 
from  a  few  minutes  to  a  half  hour  and  terminate  by  eructations,  slight 
vomiting,  and  perspiration. 

Nervous  cardialgia  is  most  frequently  observed  in  anasmic  and  hysteri- 
cal individuals,  in  diseases  of  the  uterus  and  ovaries,  and  sometimes  in 
cerebral  and  spinal  affections  and  in  dyscrasi;^.  In  the  majority  of  cases 
it  is  readily  distinguished  from  organic  affections  of  the  stomach.  Treat- 
ment:  In  the  intervals  between  the  paroxysms  we  may  employ  ferrugi- 
nous preparations,  valerianate  of  zinc,  belladonna,  bismuth,  local  treatment 
of  the  uterus,  or  methodical  hydrotherapeutic  measures  (cool  sitz-baths, 
frictions,  then  moist  packs  and  half-baths),  according  to  the  peculiarities 
of  each  individual  case.  During  the  attacks  themselves,  subcutaneous  in- 
jectionfe  of  morphine  constitute  the  most  efficient  remedy. 

Morbid  sensations  of  hunger  and  thirst  may  also  be  attributed  to  an 
irritation  of  the  sensory  fibres  of  the  stomach.  Boulimia  consists  of  a 
painful  sensation  of  hunger,  occurring  with  unusual  frequency,  appeased 
by  very  slight  nourishment,  more  rarely  by  strange  articles  of  diet,  and 
returning  at  short  intervals  with  intolerable  violence,  either  during  the 
day  or  even  during  sleep.  Boulimia  is  observed  in  hysteria,  in  extreme 
neuropathic  conditions,  in  insanity,  diabetes,  and  after  severe  fevers  and 
syphilis  (Fournier).  Treatment:  Prolonged  hydrotherapeutic  measures, 
according  to  the  principles  previously  laid  down;  the  internal  administra- 
tion of  Fowler's  solution,  opium  (preferably  as  hypodermic  injections), 
codeine  (Emminghaus,  0.01  three  times  a  day).  The  marbid  sensation  of 
thirst  or  polydipsia  is  also  a  form  of  hyperaesthesia  of  the  pneumogastric, 
in  which  the  sensory  fibres  of  the  buccal  and  pharyngeal  mucous  mem- 
branes participate.  Polydipsia  is  observed  in  the  diseases  mentioned 
above,  and  its  treatment  is  similar  to  that  of  boulimia. 


DISEASES    OF   THE    TTERVOUS    SYSTEM.  221, 

Polyphagia  constitutes  another  morbid  condition  in  which  the  patient 
is  only  satiated  after  eating  an  enormous  quantity  of  food.  Experimen- 
tal facts  and  pathological  observations  serve  to  demonstrate  an  anaesthesia 
of  the  gastric  fibres  of  the  vagus  in  these  cases.  According  to  Leg-allois, 
Brächet,  etc.,  animals  also  manifest  an  insatiable  appetite  after  section 
of  the  pneumogastric  in  the  neck.  In  Swan's  patient  (affected  with  dvsp- 
noea,  polyphagia  and  frequent  vomiting)  both  pneumogastrics  were 
found  atrophied;  in  Bignardi's  case  the  nerves  were  strewn  with  small, 
reddish  neuromata.  In  Johnson's  patient  (complete  absence  of  the  sensa- 
tions of  hunger  and  thirst)  the  medulla  oblongata  was  softened,  and  the 
roots  of  the  left  pneumogastric  nerve  were  compressed  by  an  aneurismal 
dilatation  of  the  vertebral  artery.  Polyphagia  is  also  observed  in  hys- 
teria, epilepsy,  and  insanity.  Treatment:  Opiates,  especially  subcuta- 
neously,  and  Fowler's  solution.  In  a  hypochondriac,  who  had  been  bene- 
fited by  the  Carlsbad  waters,  though  only  during  the  first  two  weeks  of 
treatment,  I  obtained  complete  recovery  from  the  polyphagic  symptoms 
after  the  continued  employment  of  hydrotherapeutic  measures. 

Finally,  nervous  vomiting  should  also  find  a  place  in  this  category. 
Independently  of  its  central  causes,  the  vomiting  may  occur  from  periph- 
eral, reflex  irritation  of  the  sensory  fibres  of  the  pneumogastric,  as  in 
irritation  of  the  auricular  branch,  of  the  respiratory  fibres,  etc.  Nervous 
vomiting  is  observed  especially  in  pregnancy,  hysteria,  and  chlorosis,  and 
frequently  accompanies  digestive  disorders,  cardialgia,  and  gastric  pneu- 
matosis. The  Dutrition  of  hysterical  patients  does  not  suffer,  even  after 
repeated  vomiting,  as  a  portion  of  the  food  is  retained.  As  a  rule,  there 
is  little  diflficTilty  in  distinguishing  these  cases  from  the  vomiting  due  to 
tissue  changes  in  the  stomach  (chronic  catarrh,  ulcer,  etc.).  Treatment: 
Anti-hysterical  remedies,  faradization  of  the  gastric  region,  subcutaneous 
injections  of  morphine,  valerianate  of  cafeine,  etc. 

Paralysis  of  the  stomach  must  be  attributed  in  great  part  to  a  diminu- 
tion in  the  energy  of  the  pneumogastric  nerves.  The  stomach  then  be- 
comes considerably  enlarged  from  the  accumulation  of  gaseous,  solid  or 
liquid  contents,  as  is  sometimes  observed  in  typhoid  fever,  cholera,  and 
gastric  degenerations.  Treatment  must  consist  in  the  attempt  to  restore 
the  energy  of  the  nervous  system  as  much  as  possible. 


c.  Diseases  of  the  Spinal  Accessory  Nerves. 

Although  the  spinal  accessory  nerve  is  composed  almost  exclusively 
of  motor  fibres,  we  are,  nevertheless,  able  to  produce  painful  sensations 
by  exercising  traction  upon  its  roots.  Hyrtl  discovered  upon  the  spinal 
accessory,  unilateral  ganglia  into  which  a  portion  of  its  fibres  enter,  and 
which  thus  demonstrate  its  sensory  properties.  If  the  external  branch 
of  the  spinal  accessory  is  extirpated  near  the  base  of  the  skull  upon  both 
sides,  and  before  its  junction  with  the  pneumogastric,  paralysis  of  the 
movements  of  the  larynx  (in  addition  to  paralysis  of  the  sterno-mastoid 
and  trapezius  muscles)  will  be  produced  in  the  same  manner  as  if  the 
recurrent  nerve  is  cut.  According  to  Schiff,  the  roots  which  preside  over 
the  movements  of  the  glottis  originate  in  the  medulla  oblongata  above 
the  calamus.  After  extirpation  of  the  twelfth  pair,  tetanization  of  the 
pneumogastric  nerve  in  the  neck  will  not  produce  arrest  of  the  hearths 
action. 

Affections  of  the  external  branch  of  the  spinal  accessory  will  give  rise 


222  CLIiaCAL    TREATISE    ON 

to  symptoms  of  spasm  or  of  paralysis.  Exposure,  diseases  of  the  upper 
cervical  vertebras,  forced  movements  of  the  head,  and  reflex  irritations 
originating  in  remote  viscera  (as  in  hysteria),  may  act  as  causes  of  mus- 
cular spasms.  These  spasms  may  be  tonic  (torticollis,  Collum  obstipum), 
and  are  then  always  unilateral,  or  they  may  be  clonic  and  occur  upon  one 
or  both  sides.  In  tonic  spasm  of  the  sterno-mastoid  muscle,  the  head  is 
turned  to  the  side  and  forwards,  the  occiput  approaches  the  shoulder,  the 
ear  the  clavicle,  and  the  chin  is  directed  towards  the  opposite  side.  In 
the  chronic  forms  there  is  very  marked  obliquity  of  the  neck  and  verte- 
bral column,  the  cervical  portion  of  which  describes  a  convexity  towards 
the  sound  side,  with  compensatory  deformity  in  the  thoracic  and  lumbar 
regions.  In  tonic  spasm  of  the  trapezius,  the  head  as  a  whole  is  drawn 
strongly  backwards  and  to  the  side,  without  rotation  of  the  chin,  the 
scapula  is  drawn  upwards,  and  the  trapezius  becomes  rigid  and  sensitive 
if  an  attempt  is  made  to  restore  the  position  of  the  head. 

In  the  diagnosis  of  tonic  spasms  depending  upon  the  spinal  accessory 
nerve,  especial  attention  must  be  paid  to  the  etiological  conditions,  to  re- 
flex irritation,  and  to  diseases  of  the  vertebrae,  and  the  treatment  must 
vary  accordingly.  Acute  rheumatic  or  traumatic  forms  often  yield  to 
warm  baths,  or  to  vapor-baths  followed  by  tepid  douches.  Chronic  cases 
are  sometimes  relieved  by  means  of  secondary  currents,  which  are  grad- 
ually intensified,  or  by  the  passage  of  stabile  galvanic  currents  through 
the  nerves  and  muscles  (sittings  of  five  to  eight  minutes). 

Unilateral  clonic  spasm  appears  in  rare  instances  as  isolated  convul- 
sions of  the  sterno-mastoid  muscles  with  a  corresponding  position  of  the 
head;  the  adjacent  muscles  (jaw,  face,  and  arm)  are  also  subject  to  spasm. 
When  the  convulsions  are  prolonged  and  increase  in  frequency,  true 
paroxysms  develop,  the  intensity  of  which  is  enormously  increased  by 
mental  excitement  and  prevents  the  patient  from  pursuing  his  occupation. 
When  the  scaleni  are  affected,  stiffness,  amesthesia,  and  oedema  of  the 
arm  may  also  develop,  according  to  Romberg,  from  compression  of  the 
brachial  plexus  and  veins. 

Bilateral  clonic  spasm  of  the  sterno-mastoids  (salaam  convulsion  of 
Newnham)  is  rarely  observed  in  adults;  in  Brodie's  patient,  it  alternated 
with  insanity.  In  the  majority  of  cases  paroxysms  of  this  affection  (of  a 
longer  or  shorter  duration,  sometimes  lasting  several  days)  are  observed 
in  children  from  the  period  of  dentition  until  the  age  of  puberty.  They 
are  attended  with  convulsions  of  the  face  and  strabismus,  and  perhaps 
even  with  general  spasms  and  disordered  consciousness.  Hitherto  it  has 
not  been  determined  by  autopsy  whether  these  extraordinary,  and  hap- 
pily rare,  spasmodic  forms  are  due  to  exudations  at  the  base  of  the  brain, 
or  to  a  hyper^emic  irritation  of  the  roots  of  the  spinal  accessory  (as  in 
some  cases  of  indigestion  or  intestinal  worms).  At  times  the  affection 
has  been  known  to  terminate  in  epilepsy,  paralysis,  or  insanity.  The 
spasms  in  question  may  also  be  due  to  other  causes,  such  as  exposure, 
traumatism,  tumors,  caries  of  the  cervical  vertebrae,  lesions  of  the  cervical 
cord,  uterine  affections,  and  hysteria. 

The  disease  does  not  always  terminate  favorably  in  children.  The 
treatment  of  clonic  spasm  of  the  sterno-mastoid  muscle  is  rarely  attended 
with  permanent  results,  whether  resort  is  had  to  hydrotherapeutics,  prep- 
arations of  zinc,  iron,  bromide  of  potassium  or  inhalations  of  chloroform. 
M.  Meyer  cured  a  case  of  spasm  of  the  face  and  of  the  sterno-mastoid  by 
faradization.  The  constant  current  has  also  proved  beneficial  at  times, 
when  applied  to  the  spinal  accessory  nerves  and  to  the  muscles,  or  under 


DISEASES    OF   THE   NERVOUS    SYSTEM.  223 

the  form  of  longitudinal  and  transverse  currents  through  the  head.  In 
severe  spasms  of  reflex  origin,  electricity  proves  as  useless  as  the  injec- 
tions of  morphine,  atropine,  derivatives,  and  orthopaedic  appliances,  which 
are  sometimes  employed.  In  three  obstinate  cases,  Busch  (Ber.  Klin. 
Wschr.,  1873)  obtained  good  results  from  the  application  of  moxge  to 
each  side  of  the  vertebral  column,  suppuration  from  which  was  kept  up 
for  a  long  time.  Myotomy  and  neurotomy  (Busch)  have  not  proven  suc- 
cessful. 

Paralysis  of  all  the  muscles  of  the  neck  (sterno-mastoids  and  trapezii) 
is  very  rarely  observed.  I  have  never  observed  its  occurrence  except  in 
one  case  of  very  marked  progressive  muscular  atrophy.  All  the  muscles  in 
question  were  reduced  to  the  thickness  of  a  sheet  of  paper,  and,  in  order  to 
prevent  the  head  from  falling  forward,  the  patient  was  obliged  to  support 
it  with  a  pasteboard  collar.  The  movements  of  the  muscles  of  the  neck 
were  reduced  to  a  minimum,  and  were  only  performed  very  feebly  after 
great  exertion.  Peripheral  paralysis  of  the  spinal  accessory  nerve  may 
be  caused  by  exposure,  traumatic  lesions,  fractures  of  the  cervical  verte- 
brae, tumors,  degenerations  of  the  lymphatic  glands,  etc.  One  or  both 
pairs  of  muscles  innervated  by  the  spinal  accessory  may  be  affected. 

In  unilateral  paralysis  of  the  sterno-mastoid,  voluntary  rotation  to- 
wards the  opposite  side  is  performed  with  difficulty,  and  the  muscles 
during  these  movements  do  not  project  so  strongly  as  in  the  normal 
condition.  If  the  unilateral  paralysis  is  prolonged,  torticollis  becomes 
established  from  contracture  of  the  healthy  muscle.  In  bilateral  paraly- 
sis of  the  sterno-mastoids,  the  power  of  rotation  of  the  head  is  markedly 
diminished,  the  projection  of  the  muscles  is  lost,  and  the  lateral  region 
of  the  neck  is  visibly  flattened. 

The  trapezius  is  often  affected  with  partial  paralysis,  especially  in  pro- 
gressive muscular  atrophy.  In  paralysis  of  the  lower  fibres,  the  scapula 
recedes  from  the  median  line  of  the  back,  and  the  shoulder  may  become 
lower.  But  if  the  scapula?  are  brought  very  close  together,  the  rhom- 
boids will  raise  the  shoulder  and  draw  it  around  its  outer  angle.  In 
paralysis  of  the  middle  fibres,  the  scapula  is  lowered  and  its  anterior  bor- 
der and  inner  angle  are  separated  from  the  vertebral  column.  In  paraly- 
sis of  the  clavicular  portion  there  is  considerable  difficulty  in  the  eleva- 
tion of  the  arm  to  the  horizontal.  In  paralysis  of  both  trapezii,  the  scap- 
ulae are  lowered  to  the  outside  and  forwards,  and  the  back  appears  larger 
and  more  strongly  arched. 


224  CLINICAL    TREATISE    ON 


II.  DISEASES  OF  THE  SPINAL  NERYES. 


CHAPTER  XLVH. 

A. — Neeyous  Disorders   ix  the   Branches   of  the   Cervical  and 

Brachial  Plexuses. 

The  first  four  pairs  of  cervical  nerves,  which  form  the  cervical  plexus, 
furnish  sensory  filaments  to  the  occiput  and  to  the  neck  as  far  as  the 
shoulder.  Among  its  branches,  the  occipitalis  major,  the  cervical  cu- 
taneous, and  the  phrenic  nerves  are  most  frequently  the  seat  of  disease. 


1.  cervico-occipital  neuralgia. 

This  neuralgia,  which  had  been  recognized  by  the  elder  Berard  but 
was  first  established  clinically  by  Valleix,  is  a  rare  affection.  It  is  most 
frequently  due  to  exposure,  much  more  rarely  to  cervical  spondylitis  or 
periostitis,  irritation  of  the  cervical  cord,  wounds  of  the  cervical  nerves, 
foreign  bodies,  adenitis,  tumors,  neuromata.  In  this  neuralgia,  the  pains 
are  sometimes  continuous,  dull  and  circumscribed,  sometimes  lancinating 
and  paroxysmal,  extending  from  the  occiput  to  the  neck  and  shoulder, 
and  rendering  the  movements  of  the  head,  or  even  of  mastication  and 
speech,  impossible. 

The puneta  dolorosa  indicated  by  Valleix  are:  1,  an  occipital  point 
between  the  mastoid  process  and  the  first  cervical  vertebra,  at  the  exit  of 
the  occipitalis  major  (in  one  of  my  cases,  this  point  corresponded  to  the 
articulation  of  the  occipital  and  parietal  bones);  2,  a  cervical  point  be- 
tween the  sterno-mastoid  and  trapezius,  a  little  above  the  median  plane 
of  the  neck,  at  the  emergence  of  the  nerves  of  the  cervical  plexus  (this 
point  is  not  constant) ;  3,  a  mastoid  point  behind  the  mastoid  process, 
corresponding  to  the  occipitalis  minor  and  auricularis  major  nerves;  4, 
a  parietal  point  at  the  circumference  of  the  parietal  protuberance,  in 
which  the  branches  of  the  frontal,  occipital,  and  auricularis  major  nerves 
meet;  5,  an  auricular  point  (not  constant)  upon  the  concha  of  the  ear. 
Cervico-occipital  neuralgia  is  sometimes  associated  with  neuralgia  of  the 
trigeminus  or  brachial  plexus.  Among  the  nutritive  disturbances,  I  have 
observed  falling  out  of  the  hairs  in  the  occipital  region.  The  diagnosis 
is  founded  on  the  existence  of  circumscribed  painful  points  and  of  parox- 
ysms starting  from  these  points.  These  data  also  distinguish  neuralgia 
from  muscular  rheumatism  of  the  neck,  which  is  of  very  frequent  occur- 
rence. In  the  latter  affection  the  pains,  instead  of  being  limited  to  cer- 
tain positions,  occupy  all  the  muscles  and  are  greatly  intensified  by  move- 
ment. Irritation  of  the  cervical  cord  is  characterized  by  associated 
symptoms;  in  cervical  spondylitis  there  are  pains  in  the  cervical  column 
upon  pressure  and  during  movements,  deflection  of  the  head  and  creaking 
of  the  joints;  the  head  is  raised  with  greater  facility  if  the  occiput  is 
supported. 

The  prognosis  of  simple  neuralgia  is  favorable;  recovery  generally 


DISEASES    OF    THE    NERVOUS    SYSTEM.  225 

requires  several  weeks  or  months,  more  rarely  years.  The  treatment^  in 
symptomatic  neuralgia,  must  be  directed  against  the  primary  disease. 
In  the  rheumatic  form,  vapor-baths  and  flying  blisters  are  employed  with 
advantage;  large  doses  of  quinine  are  recommended  in  the  intermittent 
forms,  I  cured  one  case  of  this  kind  in  six.  weeks  by  galvanization  with 
stabile  currents  of  gradually  increasing  intensity  (the  anode  upon  the 
neck,  the  cathode  upon  the  occipital  point).  In  a  second  case,  subcu- 
taneous injections  of  morphine  produced  prompt  improvement,  but  recov- 
ery was  only  obtained  at  the  end  of  several  months  by  the  employment 
of  hydrotherapeutics  (moist  packs  of  the  entire  body,  including  the  head, 
until  the  return  of  warmth,  and  followed  by  cool  half-baths  and  affusions 
to  the  head). 


3.    NERVOUS    DISORDEES    IN  THE    DISTRIBUTION    OF  THE    PHRENIC. 

The  phenomena  of  irritation  include  neuralgia  of  the  phrenic,  clonic 
spasm  of  the  diaphragm  (hiccough),  and  tonic  spasm  of  the  same  muscle, 
the  latter  being  exceedingly  rare;  among  the  symptoms  of  depression  is 
paralysis  of  the  diaphragm.  Under  the  term  neuralgia  of  the  phrenic  nerve 
(Luschka  and  Henle  regard  it  as  a  mixed  nerve),  Falet  (Montpel.  Med., 
1866)  and  Peter  (Arch.  Gen.,  t.  XVII.,  1872)  have  described  a  pain- 
ful disease,  affecting  the  base  of  the  thorax  at  the  insertion  of  the 
diaphragm,  and  radiating  upwards  to  the  neck  and  shoulder  into  the 
territory  of  the  cervical  plexus.  Upon  careful  examination,  painful  points 
will  be  found  upon  the  spinous  processes  of  the  second  to  the  sixth 
cervical  vertebra?,  upon  the  phrenic  nerve  at  its  passage  into  the  sub- 
clavicular fossa,  and  at  the  anterior  insertions  of  the  diaphragm,  which 
correspond  to  the  seventh  to  the  tenth  ribs  (more  rarely  at  the  posterior 
insertion). 

Diaphragmatic  neuralgia  accompanies  continuous  movements  of  the 
diaphragm,  is  aggravated  at  times,  predominates  usually  upon  the  left 
side,  and  is  observed  as  a  primary  affection  after  exposure  and  in  anse- 
mic  nervous  individuals.  As  a  secondary  affection,  this  neuralgia  follows 
diseases  of  the  heart  and  vessels,  Basedow's  disease,  angina  pectoris, 
diseases  of  the  liver,  etc.  The  diagnostic  signs  are  furnished  by  the 
symptoms  previously  mentioned  and  by  the  puncta  dolorosa.  The  treat- 
ment must  be  directed  towards  the  primary  disease,  combined  with  wet 
cups,  blisters,  and  subcutaneous  injections  of  morphine. 

Clonic  spasm  of  the  diaphragm  (hiccough)  consists  of  violent,  spas- 
modic contractions  of  this  muscle,  which  are  accompanied  by  an  inspiratory 
sound,  interrupted  by  momentary  spasm  of  the  constrictors  of  the  glottis; 
the  attack  terminates  in  a  short  expiration.  According  to  the  intensity 
and  duration  of  these  different  phenomena,  the  paroxysm  may  be  accom- 
panied by  pains,  retraction  of  the  epigastrium,  embarrassment  of  speech, 
and  symptoms  of  dyspnoea.  Hiccough  may  result  from  direct  irritation 
of  the  phrenic  nerve  by  tumors  of  the  mediastinum,  aneurisms,  pneu- 
monia, and  pleuritic  effusions  (if  the  mediastinal  pleura  is  also  involved). 
It  is  also  of  a  reflex  nature,  as  in  irritations  of  the  pharynx,  oesophagus, 
stomach,  intestines,  peritoneum,  in  biliary  and  renal  calculi,  and  in  dis- 
eases of  the  prostate  (Loquet)  and  uterus.  Hiccough  is  of  central  origin 
in  hysteria,  after  emotional  excitement,  hnsmorrhages,  in  cholera,  severe 
dysentery,  etc.  Its  appearance  is  an  ominous  symptom,  as  it  usually  oc- 
curs in  the  later  stages  of  severe  diseases. 
Vol.  II.— 15 


226  CLINICAL    TREATISE    ON 

In  order  to  combat  this  spasm,  which  often  constitutes  a  distressing 
and  very  obstinate  condition  (especially  in  hysteria),  the  treatment  must 
be  principally  directed  against  its  causes.  Slight  forms  are  relieved  by 
swallowing  cold  water,  pieces  of  ice,  or  acid  drinks.  In  hysterical  hic- 
cough we  may  prescribe  enemata  of  asafoetida,  hypodermic  injections  of 
morphine,  atropine  internally  or  hypodermically,  or  small  doses  of  chloro- 
form in  inhalation.  I  have  several  times  arrested  the  hiccough  by  pro- 
longed galvanization  of  the  phrenic  nerve  (daily  sittings  of  three  to  five 
minutes).  The  paroxysms  are  also  relieved  by  moist  frictions,  half-baths 
with  aflEusions  to  the  head  and  neck,  and  circling  douches  around  the 
base  of  the  thorax.  A  simple  remedy  in  rebellious  cases  is  circular 
compression  of  the  base  of  the  thorax,  with  forced  flexion  of  the  head 
upon  the  chest  for  five  to  ten  minutes.  Relaxation  of  the  diaphragm  is 
almost  always  obtained  in  this  manner.  In  obstinate  forms,  good  effects 
are  also  obtained  from  the  use  of  musk,  combined  with  alkaline  baths 
(Klein)  and  from  catheterism  of  the  oesophagus  (Carcassonne).  Coexist- 
ing affections  of  the  genital  apparatus  demand  appropriate  treatment. 

Tonic  spasm  of  the  diaphragm  (tetanus  of  the  diaphragm)  is  a  very 
grave,  but  fortunately  extremely  rare,  disease.  Its  symptomatology  has 
been  described  by  Duchenne  from  his  experiments  upon  animals,  in  whom 
contracture  of  the  diaphragm  was  produced  by  vigorous  and  prolonged 
faradization  of  the  phrenic  nerve.  The  results  thus  obtained  have  been 
since  confirmed  in  man  by  the  observations  of  Valette,  Duchenne,  Vigla, 
Oppolzer,  Nesbit-Chapman  (upon  himself),  and  Fischl.  These  cases  were 
secondary  to  exposure,  intercostal  rheumatism,  and  violent  concussion  of 
the  body.  Spasm  of  the  diaphragm  may  also  occur  as  a  partial  symptom 
in  tetanus  and  in  epileptic  and  hysterical  attacks. 

The  spasm  is  evidenced  by  severe  asphyxial  phenomena.  The  patient  rapidly  sinks 
into  collapse  ;  immobility  and  considerable  enlargement  of  the  lower  half  of  the  tho- 
rax and  of  the  abdominal  walls,  with  sinking  of  the  liver,  very  short  inspiration,  and 
prolonged  and  noisy  expiration  are  noticed.  The  face  is  cyanotic  and  anxious,  the 
pulse  is  very  small  and  slow,  the  voice  is  monotonous  and  often  interrupted  ;  there 
are  acute  pains  in  the  lower  thoracic  and  epigastric  regions.  In  Valette's  observation, 
which  terminated  fatally  in  twenty-four  hours,  autopsy  only  revealed  general  cyano- 
sis and  repletion  of  the  veins.     All  the  other  known  cases  have  rapidly  recovered. 

The  diagnosis  rests  upon  the  symptoms  which  we  have  mentioned 
and  upon  the  acute  character  of  the  disease.  According  to  Bamberger 
(Wuerzb.  Zeitschr.,  VI.  Bd.,  1865),  cases  of  this  character  should  be  re- 
garded as  a  form  of  nervous  asthma.  But  in  bronchial  spasm  there  is  no 
manifest  depression  or  immobility  of  the  diaphragm,  and  the  affection 
assumes  a  periodical  character.  The  j^t'ognosis  is  not  absolutely  unfavor- 
able if  the  patient  receives  prompt  and  active  assistance.  Vigla  applied 
compresses  soaked  in  boiling  water  to  the  lower  half  of  the  thorax.  This 
produced  intense  pain  in  the  skin,  but  without  vesiculation,  and  respira- 
tion soon  became  free.  Oppolzer  saved  his  vigorous  patient  by  a  vene- 
section amounting  to  one  pound;  at  the  same  time  he  covered  the  entire 
thorax  and  epigastric  region  with  a  mustard  poultice  and  administered 
0.12  of  morphine  internally.  We  may  also  employ  inhalations  of  chloro- 
form and  hypodermic  injections  of  a  concentrated  solution  of  morphine. 
Duchenne  employed  active  faradization  by  means  of  dry  metallic  con- 
ductors or  the  electrical  brush,  applied  around  the  nipples  or  to  the  base 
of  the  thorax.  It  would  appear  preferable  to  pass  a  constant  current 
through  both  phrenic  iierves. 


DISEASES    OF   TUE    NERVOUS    SYSTEM.  227 

Paralysis  of  the  diaphragm  sometimes  appears  as  part  s^'mptom  in 
paralysis  of  the  bulbar  nuclei,  in  progressive  muscular  atrophy,  hysteria, 
and  lead  paralysis.  Inflammation  of  the  adjacent  structures  (peritoneum 
or  pleura)  may  also  give  rise  to  partial  paralysis  of  the  diaphragm. 
Exudation  and  suppuration  then  occur  into  the  muscular  tissue  of  the 
diaphragm,  and  the  longitudinal  and  transverse  striae  disappear  in  part 
and  are  replaced  by  granulations.  This  partial  disorganization  is  show^n 
during  life  by  the  signs  of  a  unilateral  paralysis  of  the  diaphragm. 

The  following  are  the  pathognomonic  symptoms  of  paralysis  of  the 
diaphragm:  retraction  of  the  abdominal  walls  during  inspiration,  with 
dilatation  of  the  lower  part  of  the  thorax;  in  expiration,  however,  the  epi- 
gastrium and  hypochondria  sink  in  and  the  thorax  is  narrowed.  In  begin- 
ning paralysis,  the  respiration  is  more  or  less  embarrassed,  and  becomes 
especially  slow  when  the  patient  speaks  or  performs  any  movements. 
The  patient  is  orthopnceic,  and  the  intestines  appear  to  mount  into  the 
chest  during  inspiration;  the  voice  is  feeble  or  completely  abolished. 

The  causes  of  the  paralysis  may  be  determined  from  the  history  and 
previous  pathological  condition.  The  prognosis  is  unfavorable,  especially 
in  severe  forms  of  bulbar  paralysis  and  progressive  muscular  atrophy,  in 
which  the  diaphragm  is  usually  affected  towards  the  last.  Paralysis  of  the 
diaphragm  from  hysteria  or  lead-poisoning  frequently  terminates  in  re- 
covery. Treatment  consists  of  faradization  of  the  diaphragm  or  galvani- 
zation of  the  phrenic  nerves.  These  measures  are  successful  in  the 
beginning  of  the  paralysis,  but  in  old  cases  they  merely  diminish  the 
intensity  of  the  respiratory  disturbances. 


3.    CERVICO-BRACHIAL   NEURALGIA. 

Neuralgia  of  the  cervico-brachial  plexus  may  occupy  the  entire  plexus 
and  thus  involve  the  larger  portion  of  the  upper  limb,  or  it  may  be  con- 
fined to  a  few  of  the  nerves  of  the  arm.  Neuralgia  of  the  brachial  plexus 
had  been  recognized  by  Cotugno  towards  the  middle  of  the  last  century, 
but  Valleix  first  called  attention  to  the  "  painful  points,"  and  the  investi- 
gations of  Cruveilhier,  Martinet,  Neucourt,  and  Notta  have  still  further 
increased  our  knowledge  of  this  affection. 

Neuralgia  of  the  cervico-brachial  plexus  is  much  more  common  than 
that  of  the  cervico-occipital.  It  usually  occurs  upon  one  side  (most  fre- 
quently on  the  left),  rarely  on  both,  as  in  diseases  of  the  vertebra. 

We  may  mention  the  following  causes  :  the  action  of  cold  or  of  water  upon  the 
arm,  excessive  exertion,  compression  exercised  by  tumors  upon  the  plexus  or  in  the 
axillary  space,  wounds  of  the  nerves  by  foreign  bodies  or  in  bleeding,  aneurisms  of 
the  arch  of  the  aorta  (Hase),  formation  of  callus  after  fracture  of  the  first  rib  (Can- 
statt),  diseases  of  the  vertebral  column  (inflammation,  tuberculosis,  cancer),  inflam- 
matory irritation  of  the  upper  portion  of  the  cord,  chronic  lead-poisoning.  Pains 
which  radiate  into  the  arm  are  frequently  present  in  cardiac  stenosis  and  in  diseases 
of  the  liver  and  spleen. 

The  pain  sometimes  develops  suddenly  in  paroxysms  of  variable  dura- 
tion. But,  even  in  the  intervals,  pressure  over  the  brachial  plexus  in  the 
supra-clavicular  fossa  will  produce  pain,  and  we  can  recognize,  in  addition, 
certain  circumscribed  points,  which  are  the  seat  of  a  dull  pain,  and  pres- 
sure   upon    which    gives    rise   to   extreme   sensitiveness.     These  piincta 


228  CLiisriCAL  treatise  on 

dolorosa  are  :  1,  the  cervical  point,  situated  outside  of  the  lower  cervical 
vertebrae  at  the  point  of  emergence  of  the  lower  cervical  nerves;  2,  the 
suprascapular  point,  within  the  angle  formed  by  the  acromial  portion  of 
the  clavicle  and  the  acromion;  3,  the  deltoid  point,  at  the  inferior  third 
of  the  deltoid,  corresponding  to  the  circumflex  nerve;  4,  the  axillary  point, 
in  the  axillary  space  near  the  articulation  of  the  humerus,  at  which  the 
six  nerves  composing  the  brachial  plexus  are  accessible;  5,  the  superior 
median  point,  at  the  inner  border  of  the  biceps;  6,  the  superior  radial 
point,  between  the  middle  and  lower  thirds  of  the  arm,  where  the  radial 
nerve  winds  around  the  humerus  to  pass  outwards;  7,  the  superior  ulnar 
point,  at  the  elbow  between  the  inner  condyle  and  olecranon  process;  8, 
the  elbow  point,  corresponding  to  the  musculo-cutaneous  nerve;  9,  the 
inferior  radial  point,  upon  the  dorsal  surface  of  the  forearm,  at  the  place 
where  the  superficial  branch  of  the  radial  nerve  passes  between  the  supi- 
nator long,  and  brachialis  int.;  10,  the  inferior  median  point  (carpo- 
median),  where  the  median  nerve  becomes  superficial  between  the  tendons 
of  the  radialis  int.  and  palmaris  long.;  11,  the  inferior  ulnar  point  (carpo- 
ulnar),  opposite  the  former,  near  the  styloid  process  of  the  ulnar;  12,  the 
palmar  and  digital  points,  corresponding  to  the  digital  nerves  in  the  palm 
of  the  hand. 

The  other  symptoms  of  these  neuralgias  consist  of  painful  muscular 
spasms,  caused  by  an  irritation  of  the  mixed  nerves  or  by  reflex  action,  and 
of  vaso-motor  disturbances,  under  the  form  of  herpes  in  the  neck  or  arm, 
pemphigus,  urticaria,  and  panaritia.  At  the  onset  of  vertebral  and  spinal 
affections,  the  brachialgia  is  sometimes  complicated  with  intercostal  and 
sciatic  neuralgia. 

The  cUcupiosis  is  determined  from  the  history,  the  local  lesions,  the 
existence  of  painful  points  along  the  course  of  the  nerves,  and  the  peri- 
odical return  of  the  pain.  In  those  cases  in  which  it  is  symptomatic,  as 
in  affections  of  the  vertebrae,  we  are  guided  by  the  modifications  in  the 
position  and  in  the  movements  of  the  vertebral  column;  in  diseases  of  the 
cord,  by  the  well-known  symptoms  of  spinal  irritation.  Neuralgia  of  in- 
dividual nerve-fibres  (circumflex,  musculo-cutaneous,  median,  radial,  ulnar, 
internal  and  middle  cutaneous),  are  characterized  by  the  existence  of 
painful  foci  along  the  course  of  these  nerves. 

The  jyrognosis  varies  with  the  etiology,  the  duration,  and  the  extent  of 
the  neuralgia.  As  a  rule,  it  will  disappear  so  much  the  more  readily,  the 
slighter  its  intensity  and  extent,  and  the  more  rapidly  the  peripheral 
causes  can  be  removed.  The  central  forms  are  sometimes  very  rebellious, 
but  sooner  or  later  the  attacks  usually  terminate. 

Treatment:  Flying  blisters,  hypodermic  injections  of  morphine,  warm 
baths,  mineral  waters,  moist  packs  of  the  entire  body  (the  arm  being 
packed  separately)  antil  the  return  of  warmth,  and  followed  by  half-baths 
of  24°-20°  C  I  have  obtained  good  results  on  several  occasions  by  pass- 
inar  descending:  stabile  gfalvanic  currents  from  the  cervical  vertebne  to  the 
plexus  and  to  the  various  puncta  dolorosa  along  the  nerves.  Neurotomy 
of  the  superficial  nerves,  especially  in  peripheral  lesions,  has  been  recently 
employed  by  Bruns,  Langenbeck,  Nelaton,  Schuh,  Gherini,  etc.  In  the 
majority  of  cases  it  has  produced  recovery  or  at  least  cessation  of  pain 
for  several  years.  Sometimes,  also,  the  excision  of  retracted  cicatrices 
yields  good  results. 

The  nerves  of  the  brachial  plexus  also  present  other  sensory  disturbances, 
such  as  neuritis,  hypera?sthesia,  and  anesthesia.  Neuritis  (which  some- 
times terminates  in  nodosities  and  thickening  of  the  nerve)  may  follow 


DISEASES    OF   THE    NERVOUS    SYSTEM.  229 

compression,  wounds,  exposure,  typhoid  fever,  or  febrile  diseases.  For  the 
symptoms  and  treatment  of  neuritis  we  refer  to  pages  1T9,  180. 

The  hyperesthesia  may  be  of  peripheral  origin  and  accompany  brachial 
neuralgia,  or  it  is  due  to  some  central  cause,  as  in  hysteria  or  lesions  of  the 
cervical  cord. 

x\n£esthesia  is  observed  much  more  frequently  in  the  course  of  the 
brachial  nerves.  It  is  produced  by  the  following  causes:  solutions  of  con- 
tinuity after  operations,  crushing  or  tearing  of  the  nerves,  destruction  of 
the  nerves  by  adjacent  foci  of  suppuration;  compression  by  tumors,  or 
the  fractured  or  dislocated  ends  of  bones;  obstruction  to  the  circulation, 
as  in  embolism  of  the  brachial  arteries;  finally,  anfesthesia  is  sometimes 
due  to  the  action  of  cold,  moisture,  or  to  a  former  neuritis.  Among  its 
central  causes  may  be  mentioned  hysteria,  and  the  cerebral,  spinal,  and 
saturnine  affections  previously  discussed.  The  various  methods  of  treat- 
ment have  been  referred  to  in  preceding  chapters. 


4.    SPASMS    A^n    PARALYSIS    OF   THE    MUSCLES    OF   THE  ARM   AND    TRUNK. 

As  our  knowledge  of  spasmodic  affections  in  general  still  presents 
considerable  gaps,  we  are  very  frequently  left  in  doubt  as  to  the  real  origin 
of  the  spasms  which  may  occur  in  the  upper  limbs.  Here,  as  in  all  other 
analogous  diseases,  the  chief  role  is  played,  not  by  the  violence  of  the 
irritation,  but  by  the  increase  in  the  motor  excitability. 

The  disproportion  between  the  intensity  of  the  irritation  and  the  motor  effects  may 
result,  in  spasmodic  affections,  from  an  abnormal  receptivity  of  the  peripheral  motor 
apparatus.  This  may  originate  in  the  reflex  systems  which,  in  the  gray  substance, 
unite  the  sensory  fibres  and  cells  to  the  cells  into  which  the  motor  fibres  are  inserted. 
But  the  principal  cause  of  these  phenomena  is  the  exaggerated  excitability  of  the 
nervous  centres. 

The  abnormal  receptivity  of  the  peripheral  motor  apparatus  is  usually  due  to  local 
inflammations  or  traumatic  lesions.  In  such  cases  the  spasms  are  almost  always  cir- 
cumscribed and  tonic  in  character.  Reflex  action  is  the  most  frequent  cause  of  these 
spasmodic  phenomena.  It  is  extremely  difficult,  if  not  impossible,  to  determine  the 
real  point  of  departure  of  reflex  spasms.  We  may,  nevertheless,  state  that  the  morbid 
increase  of  excitability  is  due  to  one  of  the  following  causes :  diminution  of  the  in- 
hibitory action  discovered  by  Setschenow  in  the  brain  of  animals  ;  increased  irritability 
of  the  reflex  apparatus  contained  in  the  medulla  oblongata  and  spinal  cord ;  excessive 
receptivity  of  the  central  fibres  which  terminate  in  the  reflex  cells. 

Apart  from  psychical  irritation,  which  predi.=poses  to  reflex  spasms  by  irritation  of 
the  centres,  they  are  generally  produced  by  peripheral  irritation  of  parts  rich  in  nerves, 
such  as  the  integument,  mucous  membrane  of  the  digestive  apparatus,  genital  organs, 
articulations,  etc.  The  causes  of  the  spasms  may  consist  of  rheumatic,  traumatic, 
and  more  rarely  chemical  irritations,  of  circulatory  disturbances,  and  of  vaso-motor 
irritation  starting  from  the  sensory  nerves.  Finally,  the  predisposition  to  spasms, 
known  as  convulsibility,  may  be  due  to  nutritive  disturbances  (anaemia,  cachexia),  or 
to  an  hereditary  perversion  of  excitability. 

Rheumatic  muscular  spasms  (tonic)  usually  affect  the  muscles  of  the 
neck  and  shoulder,  the  sterno-mastoid,  the  clavicular  portion  of  the 
trapezius,  the  scaleni,  the  splenius,  and  the  oblique  muscles  of  the  head. 
Torticollis,  secondary  to  spasm  of  the  first  of  these  muscles,  has  been 
studied  under  the  diseases  of  the  spinal  accessory.  Contracture  of  the 
rhomboid  is  a  rare  disease  (the  inferior  angle  of  the  scapula  is  elevated 
and  drawn  nearer  to  the  median  line,  the  border  of  the  scapula  presents  a 
projection  which  is  prolonged  towards  the  neck,  and  the  deformity  is 
effaced  during  voluntary  movements  of  elevation  of  the  arm,  Duchenne). 


230  CLINICAL    TREATISE    ON" 

Treatment :  Faradization  of  the  opposing  muscle,  and  passage  of  a  stabile 
galvanic  current  through  the  nerves  and  muscles.  In  recent  cases  we  may 
prescribe  with  advantage  warm  baths  or  vapor-baths  in  addition  to  rest 
of  the  affected  muscle. 

Traumatic  contracture  consists,  as  we  have  shown  above  (page  170),  of 
a  contracture  of  certain  muscles  secondary  to  paralysis  of  their  antagonists. 
It  is  sometimes  of  reflex  origin.  Artisan's  spasm  (which  occurs  usually  in 
the  hands,  more  rarely  in  the  feet,  in  shoemakers,  tailors,  carpenters, 
locksmiths,  etc.)  is  a  painful  spasm  of  the  flexors,  produced  by  hard  labor. 
In  the  majority  of  the  cases  which  I  have  observed,  the  patients  had  at- 
tained the  age  of  puberty,  a  period  in  which  the  sexual  development  is 
accompanied  by  a  peculiar  excitability  of  the  nervous  system.  In  acute 
cases  the  spasms  are  quieted  by  enveloping  the  hand  in  warm,  moist 
cloths,  together  with  rest  in  bed.  In  combating  the  pains,  we  may  em- 
ploy warm  baths,  tartar  emetic  in  divided  doses,  and  subcutaneous  injec- 
tions of  morphine.  The  faradic  current  does  not  act  well  in  such  cases; 
on  the  other  hand,  it  is  used  with  success  in  chronic  cases,  in  which  par- 
tial pareses  and  anaesthesias  have  developed  secondary  to  relapses.  Dur- 
ing the  last  few  years  Nussbaum  has  observed  some  very  interesting 
facts  in  this  connection  (Aerztl.  Intelligenzbl.,  0,  1872).  He  has  succeed- 
ed in  curing  muscular  contractures  and  rebellious  anaesthesias  by  trac- 
tion of  the  nerves  of  the  brachial  plexus  which  had  been  laid  bare.  In 
another  case  he  relieved  ankylosis  of  the  elbow,  with  contracture  of  the 
fourth  and  fifth  fingers,  by  extension  of  the  ulnar  nerve,  which  had  con- 
tracted. 

Idiopathic  spasms  are  partial,  occur  usually  in  the  flexors,  especially 
in  children,  and  may  be  regarded  at  first  sight  as  a  symptom  of  a  central 
affection.  Analogous  phenomena  are  also  observed  in  adults  after  expo- 
sure or  severe  diseases,  in  the  course  of  typhoid  fever,  cholera,  acute  ex- 
anthemata, renal  affections,  and  in  pregnant  and  parturient  women. 
These  spasms  are  probably,  in  great  part,  of  reflex  origin.  The  treatment 
is  the  same  as  in  the  spasmodic  affections  previously  referred  to.  Moist 
packs  (until  the  return  of  an  agreeable  warmth),  followed  by  half-baths 
at  24°-2Ö°  C,  will  almost  always  cause  the  disappearance  of  the  spasmodic 
phenomena. 

Writer's  spasm  is  placed  in  this  category  by  the  majority  of  authors. 
We  have  previously  maintained,  however  (page  127),  that  it  is  a  disturb- 
ance of  co-ordination  in  the  muscles  innervated  by  the  brachial  plexus. 

Paralyses  of  the  brachial  plexus  and  of  the  trunk. — These  paralyses 
are  usually  limited  to  the  territory  of  certain  nerves,  and  are  produced  by 
lesions  of  the  nerve-trunks  or  by  myopathic  processes. 

The  obstacles  to  nervous  action  are  accompanied  by  abolition  of  vol- 
untary or  even  of  reflex  movements,  by  disorders  of  sensibility,  retarda- 
tion of  the  circulation,  low  temperature,  more  or  less  rapid  loss  of  muscu- 
lar nutrition  and  of  the  faradic  reaction  of  the  muscles-,  often  with  reten- 
tion of  galvanic  excitability.  Among  the  causes  of  these  paralyses  we 
may  mention  the  rheumatic  diathesis,  traumatic  lesions,  luxations,  the 
compression  produced  by  tumors,  periostitis,  and  neuritis. 

Duchenne  (Electris.  local.,  3°  edit.)  and  Seeligmueller  (Ber.  Klin. 
Wschr.,  1874)  have  called  attention  to  paralysis  in  infants  after  obstetri- 
cal operations  (forceps,  version,  traction). 

They  especially  involve  the  muscles  of  the  shoulder  and  arm,  and  may 
be  complicated  with  fractures  or  dislocations.  These  congenital  paraly- 
ses, w^hich  are  usually  <lue  to  a  contusion  limited  to  the  plexuses,  recover 


DISEASES    OF   THE    NERVOUS    SYSTE^f. 


231 


if  faradic  or  galvanic  treatment  is  promptly  instituted.     The  prognosis  is 
less  favorable  in  severe,  inveterate  forms.     Thus,  I  have  seen  a  case  of 


Caput  externum  M.  tricipit. -• 


N.  radialis 

M.  brachialis  int, 


M.  supinator  long. 

M.  radialis  extensor  long. 


M.  radialis  extensor  bre\is — ■/■'•-- 


Fig.  21.— Motor  points  of  outer  aspect  of  arm. 


hemiplegia  following  the  employment  of  the  forceps,  in  which  only  slight 
improvement  was  obtained  after  the  lapse  of  ten  years. 


N.  musculo-cutan. 


M.  biceps. 


N.  musculo-cutan.     i   N.  medianus, 


Cap.  intern.  M.  tricipit. 


M.  brachialis  internus. 


Ram.  N.  median!  pro  M.  pronator  teres. 
Fig.  22. — Motor  points  of  inner  aspect  of  arm. 


232  LINICAL    TKEATISE    ON 

Among  the  paralyses  of  the  muscles  of  the  arm,  the  most  frequent 
and  important  is  that  of  the  deltoid,  attended  with  abolition  of  motion 
forwards,  outwards,  or  backwards,  according  as  it  affects  the  anterior, 
middle  (most  frequent),  or  posterior  parts  of  the  muscle  (progressive  mus- 
cular atrophy).  In  total  paralysis  of  the  deltoid,  the  arm  is  immobile  and 
pendent,  and  the  patient  can  only  grasp  the  hand  after  throwing  it  for- 
wards by  means  of  the  pectoralis  major. 

The  infraspinatus  is  often  affected  at  the  same  time  (both  muscles  are 
supplied  by  the  circumflex  nerve),  and  rotation  outwards,  elevation  and 
abduction  of  the  arm,  and  the  formation  of  straight  lines  in  writing  and 
drawing  (Duchenne)  are  then  rendered  difficult  or  impossible. 

In  paralysis  of  the  teres  major,  supraspinatus,  and  subscapularis,  the 
arm  is  turned  outwards,  with  abolition  of  the  power  of  inward  rotation. 

Paralysis  of  the  sterno-mastoid  and  trapezius  has  been  referred  to  in 
the  preceding  chapter.  In  paralysis  of  the  rhomboid  (which  is  extremely 
rare)  the  inner  border  of  the  scapula  is  not  maintained  in  its  position 
against  the  thoracic  wall,  the  scapula  is  separated  from  the  trunk  at  its 
inner  border  and  inferior  angle,  and  the  movements  of  translation  of  the 
shoulder  towards  the  median  line,  and  the  movements  of  the  arm  back- 
wards, are  very  limited. 

Paralysis  of  the  serratus  magnus  is  not  very  rare.  During  repose  the 
scapula  see-saws  around  its  axis  and  approaches  the  vertebral  column  at 
its  inferior  angle,  and  the  anterior  border  is  lowered.  The  inner  border  is 
directed  obliquely  outwards  and  upwards  in  the  form  of  a  wing.  The  ex- 
tended arm  can  only  be  raised  to  the  horizontal  plane;  in  order  to  raise 
it  completely,  it  must  obtain  a,  2)oint  cVcq^^nii  externally  and  be  turned  for- 
wards. When  the  arm  is  raised  and  directed  forwards,  the  inner  border 
of  the  scapula  separates  itself  very  sharply  from  the  chest  (scapula  alata). 
This  paralysis  is  due  to  traumatism,  the  rlieumatic  diathesis,  and  to  over- 
work of  the  shoulder  muscles.  Simple  or  double  paralysis  of  the  serratus 
magnus  is  also  observed  in  progressive  muscular  atrophy,  cerebral  or  spi- 
nal paralyses,  and  after  typhoid  fever. 

Paralysis  of  the  extensors  of  the  back  (sacro-lumbalus  and  longissi- 
mus  dorsi),  following  traumatism,  rheumatism,  cerebral  or  spinal  lesions, 
progressive  muscular  atrophy,  etc.,  is  characterized  by  unilateral  scoliosis, 
and,  when  double,  by  paralytic  kyphosis,  with  inflexion  of  the  trunk. 
The  vertebral  column  cannot  be  restored  spontaneously,  but  can  be  re- 
tained passively  in  the  erect  position.  Electricity  may  prove  useful  in 
these  cases. 

According  to  Londe's  statistics,  the  radial  and  median  nerves  are,  on 
account  of  their  position,  more  exposed  to  traumatic  lesions  than  the 
other  nerves  of  the  arm.  In  paralysis  of  the  radial  nerve  and  of  the  ex- 
tensors of  the  forearm  to  which  it  is  distributed,  the  hand  and  fingers  are 
pendent  and  flexed,  the  thumb  is  adducted  and  flexed.  Elevation  of  the 
arm,  extension  of  the  fingers,  and  abduction  of  the  thumb  are  impossible 

On  account  of  the  loss  of  the  movements  of  extension  the  flexors 
also  contract  more  feebly.  Peripheral  paralysis  of  the  radial  nerve  may 
be  of  rheumatic  or  traumatic  origin  (blow  upon  the  forearm,  compres- 
sion by  crutches,  gun-shot  wounds,  compression  of  the  arm  during  a 
prolonged  sleep).  Paralysis  of  the  radial  nerve  has  also  been  observed 
in  hysteria,  progressive  muscular  atrophy,  lead  palsy,  typhoid  fever  (small 
haemorrhages  into  the  extensor  muscles,  with  degeneration  of  their  fibres 
and  nerve-filaments,  Friedberg),  We  refer  to  the  remarks  on  page,  166, 
for  the  differential  diasfnosis. 


DISEASES    OF    THE    NERVOUS    SYSTE^F. 


233 


Paralysis  of  the  median  nerve  is  very  rare  in  rheumatism;  it  is  more 
frequently  produced  by  traumatism,  luxations  of  the  shoulder,  tumors 
compressing  the  brachial  plexus,  neuritis  (typhoid  fever  and  acute  dis- 
eases), or  central  affections  (progressive  muscular  atrophy).  In  paralysis 
of  the  median  the  movements  of  pronation  of  the  forearm  are  markedly 
embarrassed,  and  flexion  of  the  hand  towards  the  radial  side  and  of  the  two 
last  phalanges  is  more  or  less  compromised.  The  supinator  longus  then 
acts  as  pronator  and  flexor.  When  the  muscles  of  the  thumb  are  para- 
lyzed, the  latter  is  extended  and  abducted  and  directed  with  the  other  fin- 


M.  supinator  long. 

M.  radialis  extensor  long.— 


M.  radialis  extensor  brevis 

M.  extensor    digitor.  communis 


M.  extens.  ossis  metacarp.  poll. 


M.  extens.  primi  intemodii  poll 


M.  iuteross.  dorsalis  I. • 

M.  inteross.  dorsalis  II. 

M.  inteross.  dorsalis  III. 


-M.  ulnaris  extensor. 
-M.  extens.  min.  dig. 

-M.  extens.  secundi  internod.  poU^ 
-M.  extens.  ind. 


•M.  abductor  dig.  min. 
-M.  interosseus  dorsalis  IV. 


Fig.  23.— Motor  points  of  extensor  aspect  of  forearm. 

gers  towards  the  palm  of  the  hand.  In  isolated  paralysis  of  the  oppo- 
nens,  the  thumb  loses  the  power  of  opposition.  In  paralysis  of  the  flexor 
and  short  adductor  of  the  thumb,  the  latter  cannot  be  brought  in  contact 
with  the  tips  of  the  other  fingers,  and  prehension  and  delicate  work  are 
rendered  impossible. 

Paralysis  of  the  ulnar  nerve  is  usually  secondary  to  traumatism  {vide  p. 
174),  fractures,  dislocations,  and  is  more  rarely  of  rheumatic  origin.  It  may 
be  also  due  to  neuritis  (after  typhoid  fever  or  acute  diseases),  or  may  consti- 
tute one  of  the  symptoms  of  progressive  muscular  atrophy.      In  paralysis 


234 


CLINICAL    TREATISE    ON 


of  the  ulnar,  the  hand  is  abducted,  and  has  lost  the  power  of  adduction 
and  flexion  at  the  wrist.  Paralysis  of  the  adductor  of  the  thumb  renders 
writing,  and  the  fixation  of  objects  in  general,  difficult;  paralysis  of 
the  muscles  of  the  little  finger  entails  the  loss  of  its  individual  move- 
ments. 

Paralysis  of  the  interossei  is  characterized  by  extension  at  the  meta- 
carpo-phalangeal   joints,  with    simultaneous   flexion  of   inter-phalangeal 


tlam.  N.  Med.  pro  M.  pronat.  teres.— 
M.  palmaris  longus 


M,  ulnaris  intern. 


M.   flex.  dig.   subl.   (dig.    I.   et  II.) 
N.   ulnaris. 


M.  flex.  dig.  subl.  (dig.  indie,  et  min.) 


Ram.  volar,  prof.  N.  ulnar 

M.  palm,  brevis 

M.  abductor  dig.  min. - - 

M.   flex.   dig.    min.- 

M.  opponens  dig.  min. 

M.    lumbriCales    II.    III.  at  IV, 


"M.  radialis  internus. 
■M.  flex.  dig.  prof, 

-M.  flex.  dig.  subl. 


I  jj -M.  flex.  poll.  long. 

Vi N.  median. 


— -— -M.  opp.  poll. 

^— M.  abduct,  poll. 

_\__,. M.  flex.  brev.  poll, 

^N,_^.— -M.  adductor  poll. 
^ M.  lumbricalis  I. 


Fig.  24. — Motor  points  of  flexor  aspect  of  forearm. 


articulations  from  predominance  of  the  flexors.  At  a  later  period  the 
dorsal  surface  of  the  hand  becomes  furrowed,  and  subluxation  and  incur- 
vation of  the  fingers  towards  the  palm  of  the  hand  (en  griffe)  occurs  (the 
deformity  is  especially  marked  in  progressive  muscular  atrophy). 

Galvanization  of  the  nerves,  alternating  with  faradization  of  the  para- 
lyzed muscles,  furnishes  the  best  results  in  the  treatment  of  paralysis  of 
the  upper  limbs.  Persistent  gymnastics  and  hydrotherapeutics  may  also 
aid  in  restoring  the  motor  power. 


DISEASES    OF    THE    NERVOUS    SYSTEM.  235 


CHAPTER   XLVIII. 

B. — Nervous  Disorders  i>r  the  Branches  furkished  by  the  Dor- 
sal Cord  and  Lumbar  Plexus. 

1.  dorso-intercostal  neuralgia. 

Under  the  term  intercostal  neuralgia  are  classed  those  pains  which 
are  situated  in  the  intercostal  branches  distributed  by  the  dorsal  nerves  to 
the  sternum  and  epigastrium. 

This  is  the  most  frequent  of  all  neuralgias.  It  is  much  more  common  on  the  left 
side  than  on  the  right,  and  is  usually  situated  in  one  or  more  of  the  intercostal  spaces 
comprised  between  the  fifth  and  ninth  ribs.  As  a  rule,  it  begins  slowly,  increases  little 
by  little  in  intensity,  and  presents,  like  other  neuralgias,  exacerbations  and  remissions. 
The  patients  complain  of  a  painful  tension  around  the  trunk  and  of  intermittent  lan- 
cinating pains  darting  from  the  back  to  the  thorax.  All  movements  which  present  a 
certain  degree  of  violence,  deep  respirations,  coughing,  mastication,  perhaps  even  the 
simple  contact  of  the  clothes,  may  give  rise  to  the  pain.  Intercostal  neuralgia  is  es- 
pecially observed  from  the  twentieth  to  the  forty-fifth  years  of  life,  and  chiefly  in  ner- 
vous females  (Valleix). 

We  know  little  concerning  the  anatomical  changes  in  the  nerves  in 
intercostal  neuralgia.  Nicod,  and  especially  Beau,  found  the  nerves  in- 
flamed or  atrophied  and  in  a  condition  of  fatty  degeneration  in  cases  of 
intercostal  pains  occurring  in  pleurisy  and  phthisis.  Neuromata  and 
thickening  of  the  sheaths  of  the  nerves  have  also  been  observed.  An 
opportunity  of  making  necroscopic  investigations  is  rarely  afforded  in 
ordinary  cases.  The  following  are  the  exciting  causes:  exposure,  trau- 
matism, over-exertion,  vertebral  affections  (inflammation,  caries,  cancer), 
diseases  of  the  ribs,  adenitis,  aortic  aneurism,  tuberculosis,  exudations 
upon  and  thickening  of  the  pleura.  Stasis  in  the  intercostal  veins  may 
also  act  as  a  cause  of  the  neuralgia.  This  occurs  more  readily  on  the  left 
side,  and  must  be  attributed,  according  to  Henle,  to  the  sinuosities  and 
longer  curves  of  the  vena  azygos  minor,  which  receives  the  blood  from 
the  inferior  intercostal  spaces.  The  repletion  of  the  venous  plexuses  on 
the  left  side  may  thus  cause  compression  of  the  nerve-roots. 

According  to  Bassereau,  intercostal  neuralgia  is  almost  always  accom- 
panied by  some  uterine  affection  (congestion,  abnormal  sensibility, 
catarrh,  and  menstrual  disorders),  but  it  appears  that  he  has  also  ranged 
cases  of  lumbo-abdominal  neuralgia  in  this  category.  Finally,  intercostal 
neuralgia  occurs  frequently  in  hysteria  and  diseases  of  the  cord. 

The ptm eta  dolorosa  in  dorso-intercostal  neuralgia  are:  a  dorsal  point, 
a  little  outside  the  spinous  process  at  the  intervertebral  foramen;  a  lateral 
point,  in  the  middle  of  the  intercostal  space  at  the  bifurcation  of  the  in- 
tercostal nerve  (this  point  is  not  constant);  a  sternal  or  epigastric  point, 


236  CLIl^ICAL   TREATISE    ON 

outside  of  the  sternum  for  the  superior  intercostal  nerves,  and  outside 
the  median  line  in  the  epigastrium  for  the  inferior  nerves. 

Circumscribed  anEesthesia  and  zona  (which  is  readily  explained  by  the 
presence  of  vaso-motor  fibres  in  the  dorsal  nerves)  are  sometimes  observed 
as  complications.  The  appearance  of  zona  may  be  attributed,  as  we  have 
seen  above,  to  the  existence  of  a  neuritis.  The  neuralgia  often  precedes 
the  eruption,  but  at  other  times  follows  it,  and  may  last  for  a  long  time 
afterwards. 

The  diagnosis  does  not  present,  as  a  rule,  any  especial  difficulty.  In 
intercostal  rheumatism,  which  is  most  readily  mistaken  for  neuralgia,  the 
pain  is  more  widespread,  increases  more  upon  motion  and  deep  respira- 
tions than  upon  pressure,  and  is  very  frequently  accompanied  by  febrile 
symptoms.  No  circumscribed  painful  spots  are  observed  in  the  lancinat- 
ing intercostal  pains  of  pleurisy,  pneumonia  and  pericarditis,  and  physical 
examination  reveals  other  characteristic  signs.  This  is  also  true* of  tuber- 
culosis, in  which  the  pain  is  usually  situated  in  the  superior  intercostal 
spaces  near  the  sternum.  Angina  pectoris  is  characterized  by  a  sensa- 
tion of  faintness,  irregularity  of  the  heart's  action,  and  absence  of  puncta 
dolorosa.  The  intercostal  pains,  which  are  symptomatic  of  spinal  affec- 
tions, are  complicated  by  other  neuralgias  of  the  arms  and  legs,  and  by 
symptoms  of  loss  of  power.  In  vertebral  affections  the  nature  of  the 
co-existing  neuralgias  is  recognized  by  the  pathognomonic  signs  previ- 
ously referred  to. 

As  a  rule,  the  i^rognosis  of  intercostal  neuralgia  is  not  unfavorable, 
but  it  very  often  pursues  a  slow  course.  In  rebellious  cases  the  disease 
may  continue  for  an  indefinite  period. 

Treatment :  This  should  be  directed,  above  all,  against  the  primary 
disease,  especially  the  anemia,  hysteria,  or  uterine  affection  which  may 
be  present.  More  or  less  ready  relief  is  obtained  by  the  employment  of 
flying  blisters,  the  endermic  or  hypodermic  administration  of  morphine, 
and  stabile  galvanic  currents  passed  through  the  vertebral  column  and 
along  the  course  of  the  intercostal  nerves.  According  to  Anstie,  the  ajD- 
plication  of  a  blister  over  the  posterior  nerve-fibres  will  also  act  favorably 
upon  neuralgia  of  the  anterior  branches,  and  will  even  prevent  the  second- 
ary development  of  herpes.  Benefit  is  also  frequently  derived  from 
moist  packs,  followed  by  half-baths  at  24''-22°  C,  local  douches,  sea-bath- 
ing, the  waters  of  Gastein,  Teplitz,  Tueffer,  Voeslau,  Tobelbad,  Wies- 
baden, Baden-Baden,  etc. 

Mastodynia  {irritable  breast  of  Cooper). — Neuralgia  of  the  mammary 
gland  should  be  regarded  as  a  variety  of  intercostal  neuralgia  (pectoral 
cutaneous  nerves).  This  view  is  supported  by  the  following  circumstan- 
ces: complication  with  brachialgia  (the  superior  branch  of  the  first  inter- 
costal nerve  takes  part  in  the  formation  of  the  brachial  plexus);  the  ap- 
pearance of  analogous  pains  in  the  inner  wall  of  the  axilla,  in  the  back 
and  shoulder,  parts  to  which  the  pectoral  cutaneous  branches  are  dis- 
tributed; finally,  the  accidental  complication  with  neuralgia  of  the 
abdominal  walls  (some  filaments  of  the  fifth  intercostal  nerve  are  dis- 
tributed to  the  abdominal  muscles). 

In  mammary  neuralgia,  which  is  observed  most  frequently  from  the 
period  of  puberty  to  the  age  of  thirty,  the  mammary  gland  is,  in  some 
places,  the  seat  of  lancinating  pains,  which  radiate  towards  the  shoulder, 
arm,  loins,  and  abdomen.  The  pains  increase  before  menstruation,  and 
diminish  in  intensity  during  the  menses.  Cooper  has  found  in  the  mam- 
mary gland  movable  nodosities  from  the  size  of  a  pea  to  that  of  a  hazel- 


DISEASES    OF    THE    NERVOUS    SYSTEM.  237 

nut,  which,  like  neuromata,  are  extremely  sensitive  to  contact.  They 
have  been  regarded  as  connective-tissue  formations.  In  a  case  reported 
by  Franque  (Med.  Halle,  1864),  the  mastodynia  was  due  to  a  carcinoma 
of  the  liver  and  stomach  (probably  a  radiated  neuralgia).  Beigel  pub- 
lished the  case  (Virch.  Arch.,  XLII.  Bd.,  1868)  of  a  girl,  nineteen  years 
of  age,  who  had  never  been  pregnant,  and  who  suffered,  at  the  age  of 
seventeen,  from  galactorrhoea,  followed  by  pains  in  both  mammfe.  In 
Fr.  Schultze's  case  (Ber.  klin.  Wschr.,  43,  1874)  a  secretion  of  colostrum 
with  double  mastodynia  was  observed  (reflex  irritation  of  the  secretory 
nerves  from  neuralgia  of  the  cutaneous  nerves  of  the  breast). 

Treatment :  Support  the  painful  breast  and  cover  it  with  a  fine  fur; 
employ  frictions  with  belladonna  ointment;  administer  opium  and  calo- 
mel (Cooper's  method)  internally.  The  treatment  indicated  for  intercos- 
tal neuralgia  will  also  apply  here  in  great  part. 


2.    T-UMBO-ABDOMINAL    NEURALGIA, 

Under  this  term  are  included  all  neuralgias  occurring  in  the  branches 
of  the  lumbar  plexus.  According  as  the  disease  affects  the  anterior  or 
the  posterior  branches  of  the  five  lumbar  nerves,  the  pains  radiate  into 
the  back  and  loins,  or  into  the  abdomen  and  external  genital  organs. 
Over  such  a  large  surface  the  neuralgic  affections  may  be  situated  in 
various  nerve-fibres,  and  we  accordingly  distinguish  lumbo-abdominal 
neuralgia,  properly  speaking,  neuralgia  of  the  testis,  hysteralgia,  neural- 
gia of  the  obturator  nerve,  and  crural  neuralgia. 

a.  Lumho-ahdominal  neuralgia. — This  is  most  frequently  produced 
by  affections  of  the  lumbar  portion  of  the  vertebral  column  or  the  neigh- 
borhood of  the  lumbar  plexus,  by  pelvic  diseases,  or  by  exudations  upon 
the  ilio-psoas  muscle.  Strains,  contusions,  exposure,  and  hysteria  are  re- 
garded as  pathogenic  factors.  The  pains  occur  in  paroxysms.  They  are 
usually  lancinating  in  character,  and  follow  the  course  of  the  nerves  towards 
the  posterior  portion  of  the  trunk  or  the  hypogastric  region,  or  are  mani- 
fested upon  pressure  over  certain  parts  of  these  regions.  The  puncta 
dolorosa  are:  1,  a  lumbar  point,  a  little  to  the  outside  of  the  spinous 
processes  of  the  upper  lumbar  vertebrae;  2,  an  iliac  point,  above  the 
middle  of  the  crest  of  the  ilium,  where  the  ilio-hypogastric  nerve  pene- 
trates the  transversalis  abdominis  muscle;  3,  a  hypogastric  point,  above 
the  inguinal  canal,  a  little  outside  of  the  linea  alba,  where  the  ilio- 
hypogastric nerve  traverses  the  aponeurosis  of  the  external  oblique  mus- 
cle; 4,  an  inguinal  point;  5,  a  scrotal  or  labial  point,  upon  the  scro- 
tum or  labium  major.  Spasm  of  the  cremaster  and  increase  of  sexual 
appetite  (priapism  and  ejaculation,  Notta)  sometimes  occur  as  complica- 
tions. 

Lumbo-abdominal  neuralgia  may  be  mistaken  for  rheumatic  myalgia 
(of  the  sacro-lumbalis  and  longissimus  dorsi).  But  in  the  latter  affection 
sufficient  diagnostic  data  are  found  in  the  pathognomonic  position  of  the 
vertebral  column  (convexity  towards  the  affected  side),  in  the  sensibility 
of  the  entire  muscle  to  pressure,  and  especially  during  motion,  and  in  the 
absence  of  circumscribed  inmcta  dolorosa.  Uterine  affections  (chronic 
infarctus,  cancer),  which  are  sometimes  accompanied  by  pains  in  the  back, 
hips,  and  groins,  are  readily  recognized  by  a  vaginal  examination.  Prog- 
nosis and  treatment  are  the  same  as  in  intercostal  neuralgia. 


238  CLINICAL    TREATISE    ON 

b.  JS^euralgia  of  the  testis. — This  exceedingl}'^  distressing  affection 
(irritable  testis  of  Cooper;  neuralgia  of  the  spermatic  plexus,  according 
to  Romberg)  is  characterized  by  painful  sensations  in  the  testicle,  sper- 
matic cord  and  perineum,  which,  without  any  visible  change,  become  ex- 
tremely sensitive  to  pressure  over  certain  parts.  It  is  due  to  venereal  ex- 
cesses, onanism,  unsatisfied  sexual  excitement,  chronic  urethritis,  and 
irritation  of  the  spinal  cord.  In  a  case  under  my  observation  (Wien, 
Med.  Zeit.,  9,  1864),  the  urethra  was  hypernesthetic,  and  a  fluid  like  the 
white  of  egg  was  discharged  after  micturition.  The  microscope  showed 
the  presence  of  filaments  of  mucus,  but  no  spermatozoa  (gonorrhoeal  se- 
cretion furnished  by  the  follicles  of  the  prostate,  Cowper's  glands,  or  the 
seminal  vesicles). 

The  theory  of  an  inflammatory  affection  is  contradicted  by  the  normal 
appearance  of  the  testicle.  Nephritic  colic,  in  Avhich  the  pains  radiate 
into  the  groin  and  testis,  is  distinguished  from  neuralgia  of  the  testis 
by  the  disorders  in  the  urinary  secretion  and  the  appearance  of  concre- 
tions, gravel,  and  blood  in  the  urine.  Beginning  spinal  affections  are 
characterized  by  coexisting  motor  and  sensory  disturbances.  The  acute 
cases  run  a  much  more  favorable  course  than  the  chronic  ones.  The  latter 
often  continue  for  years,  are  apt  to  return,  and  the  pains  sometimes  be- 
come so  intense  that  the  patients  demand  castration.  This  operation  has 
been  performed  several  times  by  surgeons,  but  has  not  always  resulted 
successfully.  IVeatment  :  In  acute  cases  benefit  is  obtained  from  frictions 
with  belladonna  ointment  upon  the  testis  and  along  the  cord  (two  or  three 
times  daily)  and  from  warm  baths.  In  chronic  cases  we  may  prescribe 
flying  blisters,  and  pass  a  descending  constant  current  through  the  lum- 
bar spine  and  spermatic  cord.  Resort  is  also  had  to  cool  sitz-baths,  moist 
packs,  half-baths,  cool  dorsal  affusions,  fine  douches  to  the  vertebral  col- 
umn and  perineum,  and,  finally,  sea-baths — sexual  indulgence  being  limit- 
ed as  much  as  possible. 

0.  H'jsteralgia. — Uterine  neuralgia  (irritable  uterus  of  Gooch)  is  also 
an  extremely  distressing  and  rebellious  affection.  The  uterus,  although 
maintaining  its  normal  volume,  mobility,  and  temperature,  becomes  the 
seat  of  extremely  violent  spontaneous  pains,  and  is  usually  so  sensitive 
to  pressure  that  examination  is  rendered  impossible.  Narcotics  and 
nervines  have  proved  useless  in  the  cases  observed  by  Scanzoni.  Thermal 
waters,  hydrotherapeutics,  and  sea-baths  are  probably  the  measures  which 
will  give  the  best  results  in  this  affection. 

d.  Neuralgia  of  the  obturator  nerve,  a  very  rare  form,  has  been  observed 
in  cases  of  strangulated  obturator  hernia.  It  consists  of  acute  pains 
upon  the  inner  surface  of  the  thigh,  with  abolition  of  the  power  of  ab- 
duction, and  comes  on  after  the  symptoms  of  strangulation. 

e.  Crural  neuralgia. — This  neuralgia  is  manifested  by  paroxysms  of 
pain  upon  the  anterior  and  inner  surfaces  of  the  thigh  and  leg,  extend- 
ing to  the  inner  border  of  the  dorsal  surface  of  the  foot  and  large  toe. 
As  a  pure  neuralgia  it  is  much  rarer  than  the  analogous  affection  upon 
the  posterior  surface  of  the  leg;  both  forms  are  often  associated.  The 
causes  of  this  affection  include  exposure,  traumatism,  compression  of  the 
lumbar  plexus  in  the  pelvis  by  degenerated  lymphatic  glands,  exudations 
upon  the  iliac  muscle,  aneurisms  of  the  iliac  artery,  strangulated  crural 
herni.'B,  dislocations  of  the  thigh,  coxalgia,  etc. 

T\iQ  puneta  dolorosa  are:  1,  a  crural  point,  at  the  exit  of  the  crural 
nerve  below  Poupart's  ligament;  2,  an  anterior  femoral  point,  where  the 
small    saphenous   nerve   perforates   the   fascia  lata   in  the   middle  of  the. 


DISEASES    OF    THE    NEEVOUS    SYSTEM.  239 

thigh;  3,  an  articular  point,  at  the  inner  surface  of  the  knee,  where  the 
nerve  divides;  4,  a  plantar  point,  at  the  inner  side  of  the  sole  of  the 
foot;  5,  a  point  upon  the  tuberosity  of  the  great  toe:  the  two  latter 
points  belong  to  the  anterior  saphenous  major  nerve.  Hyperaesthesia  or 
partial  ansesthesia  and  formication  are  sometimes  observed  along  the 
course  of  the  small  saphenous  nerve.  With  regard  to  prognosis  and 
treatment,  we  refer  to  the  remarks  on  sciatica. 


240  CLINICAL   TREATISE    ON 


CHAPTER  XLIX. 

C — Nervous  Disokdees  in  the  Branches  of  the  Saceo-Cocctgeal 

Plexus. 

a.  Sciatic  Neuralgia. 

Sciatica  affects  the  sciatic  plexus,  which  is  formed  by  the  fourth 
and  fifth  lumbar  and  the  first  two  sacral  pairs  of  nerves.  The  neu- 
ralgia, starting  from  the  lower  lumbar  region,  occupies  the  buttock  and 
thigh,  and  also  extends  to  the  popliteal  fold  and  the  adjacent  part  of  the 
calf  of  the  leg;  it  sometimes  extends  to  the  external  malleolus,  the  heel, 
and  the  outer  surface  of  the  foot.  In  the  majority  of  cases  the  neu- 
ralgia is  limited  either  to  the  upper  or  lower  segment  of  the  course  of 
the  nerve. 

The  ayiatomical  lesio7is  of  sciatica  are  very  imperfectly  known.  In 
one  case,  Cotugno  found  a  dropsical  enlargement  of  the  nerve,  which  was 
very  probably  due  to  the  general  anasarca  from  which  the  patient  was  suf- 
fering. Andral,  Gendrin,  and  Martinet  have  several  times  seen  the  nerve 
red  and  injected  and  the  neurilemma  infiltrated  with  serum  or  pus.  Beclard 
found  the  nerve  of  a  yellowish  color,  strewn  with  small  haemorrhages,  and 
thickened  in  places,  and  Bichat  found  it  coursed  by  dilated  vessels.  Du- 
puytren, in  a  case  of  cancer,  and  Noegelo,  in  a  case  of  elephantiasis  of  the 
thigh,  have  observed  the  formation  of  nodosities  and  cysts  upon  the 
tibial  nerve.  At  the  point  of  emergence  of  the  nerves  belonging  to  the 
sciatic  plexus,  Hasse  has  seen  the  neurilemma  inflamed  by  a  deposit  of 
tubercular  granulations,  although  no  tubercles  could  be  discovered  in  the 
spinal  canal  or  nerves. 

In  a  case  of  sciatica,  caused  by  an  ulcerated  cancer  of  the  uterus  (Med. 
Zeit.,  13-13,  1864),  I  found  the  neurilemma  of  the  sciatic  nerve  ecchy- 
mosed  and  even  sclerosed,  and  drawn  towards  the  neoplasm,  the  latter 
extending  to  the  sheath  of  the  nerve.  Microscopical  examination  of  the 
nerve,  after  hardening  in  chromic  acid,  gave  the  following  results  ;  con- 
siderable development  of  interstitial  connective  tissue  around  the  trans- 
verse sections  of  the  nerve-fibres,  with  infiltration  of  large  cancer-cells 
of  various  shapes,  and  provided  with  one  or  two  nuclei.  In  a  second 
case  of  sciatica,  which  had  continued  for  a  year,  and  had  developed  after 
confinement,  an  abscess  finally  formed  in  the  sacral  region.  Upon  open- 
ing it,  foetid  pus  escaped  and  the  bone  was  found  roughened.  The  patient 
died  of  pyaemia,  and  autopsy  showed  caries  of  the  sacro-iliac  symphysis; 
in  the  pelvis  an  abscess  was  found  around  the  left  sciatic  nerve,  the 
sheath  of  which  was  uneven  and  thickened  and  the  nerve-fibres  red  and 
surrounded  by  dilated  vessels. 

Sciatica  rarely  begins  with  suddenness  and  violence,  but,  in  the 
majority  of  cases,  the  pains  develop  gradually.  As  in  other  neuralgias, 
there  is  usually  a  dull  pain  in  the  deeper  parts,  especially  in  the  buttock, 
which,  from  time  to  time,  radiates  upwards  or  downwards,  either  spon- 


DISEASES    OP   THE    NERVOUS    SYSTEM.  241 

taneously  or  from  an  external  cause,  under  the  form  of  burning  or  lan- 
cinating pains. 

The  following  are  the  puncta  dolorosa  found  in  sciatica:  1,  the  lum- 
bar point,  upon  the  lateral  portion  of  the  last  lumbar  vertebras  (accord- 
ing to  Romberg,  this  is  an  associated  sensation  situated  in  the  posterior 
branches  of  the  sacral  nerves) ;  2,  the  posterior  iliac  point,  at  the  poste- 
rior superior  spinous  process  of  the  ilium;  3,  the  sacral  point  (of  Trous- 
seau), over  the  sacral  vertebrae;  4,  the  superior  iliac  point,  upon  the  mid- 
dle of  the  crest  of  the  ilium;  5,  the  median  iliac  point,  at  the  summit  of 
the  sciatic  foramen;  6,  the  inferior  iliac  or  trochanteric  point,  at  the 
posterior  border  of  the  great  trochanter;  7,  the  superior  femoral  point, 
upon  the  tuber  ischii;  8,  the  middle  femoral  point,  corresponding  to  the 
posterior  cutaneous  nerve;  9,  the  inferior  femoral  point,  at  the  inferior 
and  inner  part  of  the  biceps  (the  two  latter  are  inconstant);  10,  the  pop- 
liteal point,  at  the  division  of  the  sciatic  nerve;  11,  a  point  at  the  head 
of  the  fibula,  where  the  bone  is  encircled  by  the  peroneal  nerve;  12,  the 
deep  fibular  point,  at  which  the  pains  extend  for  a  certain  distance;  13, 
the  sural  point,  upon  the  calf;  14,  the  tibial  point,  at  the  edge  of  the 
tibia;  15,  the  external  malleolar  point;  16,  the  internal  malleolar  point 
(much  rarer);  17,  the  dorsal  point,  at  the  toes;  18,  the  plantar  point, 
upon  certain  parts  of  the  sole  of  the  foot. 

The  most  frequent  and  marked  of  these  painful  points  are  those  of  the  lumbar 
region,  the  great  trochanter,  the  tuber  ischii,  the  popliteal  space,  the  head  of  the 
fibula,  and  the  external  malleolus.  Nevertheless  one  or  the  other  of  these  points  is 
often  wanting,  and  in  certain  sciaticas  (especially  those  of  spinal  origin)  no  painful 
point  can  be  discovered  upon  pressure. 

In  acute  cases  the  patients  are  compelled  to  remain  in  bed,  and  are 
most  comfortable  when  the  thigh  is  brought  closer  to  the  trunk  and 
the  knee  is  slightly  flexed.  Every  forcible  movement,  such  as  turning 
in  bed,  and  coughing  or  sneezing,  and  prolonged  decubitus  upon  the 
affected  side,  increase  the  pain.  At  first  the  pain  prevents  the  patient 
from  using  the  affected  limb  in  walking.  After  a  while  locomotion 
again  becomes  possible,  but  it  is  attended  wäth  a  peculiar  one-sidedness 
and  lameness,  as  the  patients  bear  the  weight  of  the  body  upon  the 
healthy  limb  and  walk  upon  the  toes  of  the  affected  leg.  The  patients 
are  bent  somewhat  backwards  and  advance  by  inclining  forwards  slightly 
at  each  step. 

The  accompanying  motor  symptoms  and  complications  consist  of  re- 
flex muscular  spasms,  and  sometimes  of  persistent  contractures  (of  the 
biceps)  and  pareses,  especially  in  neuralgias  of  central  origin.  The  sen- 
sory disturbances  consist  of  hyperresthesia  (over  circumscribed  spots, 
especially  in  the  lancinating  sciatica  of  beginning  ataxia)  or  anaesthesia. 
I  observed  one  case  of  severe  sciatica  (Wien.  Med.  Zeit.,  12,  18G3), 
attended  with  hyperesthesia  of  the  calf  and  anaesthesia  of  the  anterior 
surface  of  the  thigh. 

Among  the  vaso-motor  disorders  we  may  observe,  in  addition  to  sub- 
jective sensations  of  cold  in  the  affected  leg,  a  diminution  of  tempera- 
ture (1.5-2°C.  in  chronic  cases),  diminution  of  the  perspiration,  and  atro- 
phy of  the  affected  side.  In  acute  cases  the  absence  of  movement  may 
undoubtedly  be  looked  upon  as  the  cause  of  the  atrophy.  But  in  severe 
and  chronic  forms  in  which  the  atrophy  chiefly  involves  the  diseased  limb, 
we  must  admit  that  the  irritated  sensory  fibres  act  by  reflex  means  upon 
the  vaso-motor  apparatus,  and  that  the  atrophy  is  due  to  the  prolonged 
Vol.  II.— 16 


242  CLINICAL    TEEATISE    ON 

contraction  of  the  vessels.  The  low  temperature  and  the  diminution  in  the 
secretions  also  favor  this  view.  Graves  reported  a  case  in  which  the  af- 
fected limb  presented  a  considerable  hypertrophy,  which  disappeared 
after  a  month's  treatment  with  the  actual  cautery.  Braun  (in  his  Bal- 
neotherapeutics) has  several  times  observed  sugar  in  the  urine  of  patients 
suffering  from  sciatica. 

Exposure  plays  the  most  important  part  in  the  etiology  of  sciatica. 
The  largest  number  of  cases  occur  in  those  months  which  are  accom- 
panied by  strong  winds  and  low  barometric  pressure. 

Exposure  to  winds  and  moisture,  contact  with  the  damp  ground,  in- 
sufficient clothing,  and  living  in  damp  places  are  the  most  frequent  causes 
of  sciatica,  especially  in  artisans.  The  disease  is  much  more  infrequent 
among  the  better  classes.  Injuries,  wounds,  over-exertion,  and  sudden 
movements  may  also  lead  to  the  development  of  sciatica. 

Symptomatic  sciatica  may  occur  under  the  following  conditions;  in- 
flammation of  the  sciatic  nerve,  diseases  of  the  sacrum  (caries,  cancer), 
pelvic  tumors,  periostitis  of  the  ilium,  perimetritis,  uterine  and  ovarian 
tumors,  pregnancy,  displacements  of  the  uterus  (compression  of  the  sa- 
cral plexus),  hypertrophy  of  the  retro-peritoneal  glands,  peritoneal  exuda- 
tions and  abscesses  (Niemeyer),  concretions  of  solid  f?ecal  matter,  accu- 
mulation of  cherry-pits  in  the  sigmoid  flexure,  tumors  along  the  course  of 
the  nerves  of  the  thigh  and  leg,  popliteal  aneurisms.  Sciatica  may  also 
be  due  to  spinal  affections,  hysteria,  and  metallic  poisoning,  and  may  fol- 
low the  puerperal  condition,  typhoid  fever,  syphilis,  and  gonorrhoea.  Fi- 
nally, it  may  occur  as  a  reflex  phenomenon  in  dental  and  facial  neuralgias 
(Brown-Sequard  and  Piorry). 

The  male  sex,  being  more  exposed  to  vicissitudes  than  the  female,  is 
also  more  liable  to  sciatica.  In  the  large  majority  of  my  cases  the  pa- 
tients were  between  the  ages  of  twenty-five  and  thirty-three  years;  the 
youngest  patient  was  a  girl  twelve  years  of  age,  the  oldest  was  a  man  of 
seventy.  The  neuralgia  is  usually  limited  to  one  side,  but  Valleix,  Leu- 
buscher,  Romberg,  etc.,  have  observed  the  bilateral  form.  All  my  cases 
of  double  sciatica  were  accomjDanied  by  spinal  symptoms. 

As  a  rule,  the  diagnosis  of  sciatica  does  not  present  any  serious  diffi- 
culties. Neuritis  of  the  sciatic  nerve  is  usually  characterized  by  febrile 
movement  and  continuous  pains  along  the  course  of  the  nerves  without 
any  circumscribed  painful  points,  and  terminates,  in  severe  cases,  with 
symptoms  of  motor  and  sensory  paralysis. 

In  rheumatism  of  the  muscles  of  the  hip  (rheumatic  myalgia)  the 
symptoms  consist  of  swelling,  elevation  of  temperature,  and  widespread 
pains,  with  absence  of  the  characteristic  puncta  dolorosa.  The  pains  are 
more  readily  produced  by  movement  than  by  pressure.  Psoas  abscess  is 
accompanied,  like  sciatica,  by  pains  in  the  hip  and  lumbar  region;  but  the 
flexion  and  retraction  of  the  thigh,  the  acute  pains  upon  forced  extension, 
the  fever  of  suppuration,  the  oedema  of  the  limb,  the  swelling,  and  the 
fluctuation  upon  the  inner  side  of  the  thigh,  constitute  distinctive  signs 
of  the  former  affection. 

Among  the  osseous  affections,  periostitis  of  the  femur  and  coxalgia 
may  be  mistaken,  in  the  beginning,  for  sciatica.  But  periostitis  of  the 
femur  begins  with  elevation  of  temperature,  and  this  is  followed  by  swell- 
ing and  a  deep  pain,  which  is  only  increased  upon  active  pressure.  In 
coxalgia  the  beginning  of  the  articular  inflammation  is  shown  by  the  pain 
upon  motion  (especially  upon  rotation  of  the  thigh),  and  also  by  striking 
upon  the  heel  and  thus  acting  upon  the  head  of  the  femur.     At  a  later 


I 


DISEASES    OF   THE    NEEVOUS    SYSTEM.  243 

period  the  enlargement  of  the  hip,  the  effaced  gluteal  fold,  the  dissimilar 
position  of  the  lower  limbs,  and  the  communication  of  movements  of  the 
thigh  (in  the  horizontal  position)  to  the  pelvis,  prevent  a  mistake. 

Certain  vascular  affections,  such  as  embolism  and  thrombosis,  are  also 
accompanied  by  pains  in  the  thigh.  In  embolism  of  the  crural  artery  the 
character  of  the  disease  is  shown  by  the  absence  of  pulsation  below  the 
obliterated  point,  by  the  absence  of  puncta  dolorosa,  and  by  the  coolness 
of  the  limb. 

Phlyctenular,  filled  with  a  reddish  fluid,  and  the  signs  of  gangrene  soon 
make  their  appearance.  Thrombosis  of  the  crural  veins  is  recognized  by 
the  cyanosis  and  oedema  and  by  the  distention  of  the  lower  veins,  espe- 
cially upon  the  dorsal  surface  of  the  foot.  If  the  patients  are  not  obese, 
we  will  be  able  to  detect  the  cord  formed  by  the  obliterated  vein. 

When  sciatica  is  symptomatic  of  spinal  affections,  it  involves  both 
sides,  at  least  at  intervals.  The  puncta  dolorosa  are  often  wanting,  and 
the  pain  is  combined  with  other  symptoms  of  motor  and  sensory  irritation. 
The  sciatic  pains  which  sometimes  occur  in  hysterical  and  saturnine  affec- 
tions are  almost  always  accompanied  by  other  characteristic  signs.  It  is 
often  much  more  difficult  to  determine  whether  a  sciatica  of  recent  date 
is  of  rheumatic  or  spinal  origin.  When  the  sciatica  is  accompanied  by 
shooting  pains  or  some  points  of  cutaneous  hyper^esthesia,  or  when  it  is 
combined  with  ocular  paral^'ses,  and  with  diplopia;  when  it  occurs  with 
other  vague  neuralgias,  after  long-continued  masturbation  or  obstinate 
pollution;  when  it  develops  in  the  midst  of  phenomena  indicative  of  geni- 
tal irritation  (frequent  seminal  losses  with  increase  of  the  neuralgic  pains, 
precipitate  ejaculations,  incomplete  erections,  disagreeable  sensations  in 
the  back  or  legs  after  coitus),  or  is  accompanied  by  abnormal  sensitive- 
ness to  lower  temperature  or  electrical  stimulation, — it  should  be  re- 
garded as  indicative  of  an  irritation  in  the  cord  (especially  of  beginning 
ataxia). 

The  2^'>'ognosis  of  sciatica  depends  upon  the  character  of  the  affection. 
The  idiopathic,  rheumatic,  or  traumatic  forms,  those  which  follow  the 
puerperal  condition,  typhoid  fever,  or  syphilis,  and  those  in  which  an  ex- 
isting compression  of  the  nerves  may  be  removed  by  an  operation,  are 
susceptible  of  recovery.  In  the  same  manner  the  sciatic  pains,  which 
sometimes  occur  in  hysteria  and  lead-poisoning,  may  be  relieved  by  treat- 
ing the  primary  disease. 

As  a  rule,  the  recovery  of  idiopathic  forms  occupies  weeks  or  even 
months.  Recent  cases,  in  young  and  previously  healthy  individuals,  ter- 
minate more  rapidly  than  chronic  neuralgias  occurring  in  old  people, 
although  the  latter  are  not  hopeless.  Inveterate  sciaticas,  which  readily 
relapse  and  resist  all  treatment,  the  bilateral  forms  and  those  which  are 
symptomatic  of  spinal  affections,  almost  always  present  an  unfavorable 
prognosis. 

Treatment. — Local  bleeding  is  indicated  (wet-cups,  leeches;  in  case 
of  haemorrhoids,  leeches  to  the  anus)  in  very  painful,  acute  cases,  and  in 
robust  individuals.  But  we  are  frequently  compelled  to  resort  to  subcu- 
taneous injections  of  morphine  in  order  to  diminish  the  violence  of  the 
pain  and  to  enable  the  patient  to  obtain  rest.  Rapid  improvement  is 
sometimes  obtained  by  applying,  for  several  successive  days,  flying  blisters 
to  the  painful  points,  especially  over  the  posterior  branches  upon  the 
sacrum  (Anstie),  and  by  rubbing  the  blistered  parts  with  a  little  morphine 
mixed  with  olive  oil  or  fat.  Betz  has  recently  advised  the  prolonged  ap- 
plication, behind  the  trochanter,  of  a  nitrate  of  silver  ointment  until  it 


244  CLINICAL   TEEATISE    ON 

drops  off  spontaneously  (powdered  nitrate  of  silver,  1-1.50  grains;  adipis, 
15  grains). 

Turpentine  has  been  highly  recommended  by  Romberg,  Recamier,  and 
Trousseau.  It  is  prescribed  with  honey  (one  to  five  grammes  of  turpen- 
tine to  thirty-five  grammes  of  honey,  one  teaspoonful  morning  and  even- 
ing) in  capsules  or  in  pills,  to  which  magnesia  has  been  added  (Oppol- 
zer).  It  is*not  well  tolerated  by  many  patients,  and  in  such  cases  can 
only  be  employed  externally. 

Frictions  with  croton  oil  upon  the  posterior  surface  of  the  thigh  and 
leg  are  also  employed,  but  it  must  usually  be  applied  several  times  before 
eczema  and  pustules  are  produced.  In  order  to  diminish  the  burning  sen- 
sation produced  by  these  eruptions,  the  limb  may  be  covered  with  moist 
compresses  and  then  with  powdered  starch.  In  the  Vienna  General  Hos- 
pital I  have  obtained  good  results  from  the  use  of  croton  oil,  even  in  obsti- 
nate cases. 

One  of  the  best  revulsive  measures  consists  of  linear  cauterization 
with  a  thin  cautery.  But  the  employment  of  this  measure  meets  with  an 
almost  insurmountable  obstacle  in  the  fears  of  the  patient,  and  a  second 
application  is  rarely  permitted.  We  may  then  resort  to  cauterization  with 
sulphuric  acid  along  the  course  of  the  painful  nerves.  Kollas  (Harless 
Annalen,  X.  Bd.)  and  Malgaigne  have  advocated  a  measure  which  is  made 
use  of  in  veterinary  medicine,  viz.:  the  cauterization  of  the  lobe  of  the  ear 
upon  the  anterior  surface  of  the  helix  on  the  affected  side.  Section  of  the 
peripheral  nerves  is  only  applicable  to  small  nerve-fibres,  and  has  not  given 
very  good  results  in  the  majority  of  cases  in  which  it  has  been  hitherto 
performed.  As  a  rule,  the  operation  causes  quite  extensive  paralysis  of 
motion  and  sensation.  In  one  of  Dieffenbach's  cases,  which  was  published 
by  Romberg  (excision  of  a  neuroma  of  the  sciatic  nerve),  persistent  ul- 
ceration of  the  heel  occurred  together  with  osseous  suppuration  (trophic 
disorders  from  traumatic  nerve  lesions).  In  many  instances  the  patients 
died  of  pyaemia.  We  may  finally  add,  with  regard  to  surgijcal  treatment, 
that  Patruban  (Allg.  Wien.  Med.  Zeit.,  43-53,  1872)  cured  a  rebellious 
case  of  sciatica  by  exposing  and  stretching  the  nerve  (Nussbaum's  opera- 
tion). 

Combining  derivative  treatment  with  narcotics.  Trousseau  prescribed, 
in  obstinate  sciatica,  narcotic  boluses  (equal  parts  of  extract  of  belladonna 
and  opium,  with  powdered  guaiac  and  mucilag.  gvim  tragacanth),  which 
were  introduced  at  night  in  an  incision  made  above  the  sciatic  notch. 
During  the  day  the  premature  closure  of  the  wound  was  prevented  by  the 
introduction  of  two  or  three  peas.  In  the  sciatica  following  confinement, 
Basedow  has  several  times  obtained  recovery  by  bandaging  the  leg  from 
the  toes  to  the  knee. 

As  thermal  treatment  we  may  prescribe,  especially  in  chronic  sciatica, 
the  sulphur  waters  of  Wiesbaden,  Aix-la-Chapelle,  Baden  (near  Vienna), 
Gastein,  Pistyan,  Teplitz,  Trentsin,  etc.  In  those  cases  which  are  accom- 
panied by  symptoms  of  irritation  on  the  part  of  the  cord,  mineral  waters 
of  high  temperature  are  usually  tolerated  poorly,  and  are  apt  to  increase 
the  medullary  symptoms. 

In  peripheral  sciatica  good  results  are  obtained  from  faradic  treat- 
ment (secondary  current  applied  to  the  painful  points  for  five  to  ten  min- 
utes by  means  of  dry  electrodes),  and  from  the  descending  stabile  current 
(the  anode  upon  the  lumbar  plexus  and  nerve-roots,  the  cathode  upon  the 
painful  points).  Weak  currents  are  used  in  the  beginning,  and  their  in- 
tensity may  then  be  increased.     In  some  cases  in  which  electricity  is  not 


DISEASES    OF   THE   NEEVOUS    SYSTEM.  245 

well  borne,  its  use  may  be  preceded,  for  a  certain  length  of  time,  by  sub- 
cutaneous injections  and  baths.  In  sciatica  of  central  origin,  electricity 
often  produces  merely  palliative  effects,  and  the  relapses  demand  long- 
continued  thermal  or  hydrotherapeutic  treatment. 

The  hydrotherapeutic  treatment  of  sciatica  includes  various  procedures. 
In  Fleury's  method  the  patient,  wrapped  in  woollen  cloths,  is  placed 
in  a  sweating  apparatus,  heated  by  an  alcohol  lamp;  the  head,  covered 
with  moist  compresses,  protrudes  from  the  sweat-chest.  The  patient 
remains  in  this  position  from  ten  to  twenty  minutes  until  he  perspires 
profusely,  and  then  takes  a  cool  bath  or  douche.  The  "  douche  ecossaise  " 
consists  of  a  shower-bath  in  which  warm  and  cold  water  are  used  alter- 
nately. When  the  warm  douche  has  been  applied  to  the  affected  leg  to 
the  limit  of  the  patient's  endurance,  it  is  followed  by  a  local  or  general 
cold  douche.  Recent  cases  are  also  benefited  by  vapor-baths  followed  by 
moist  frictions.  Some  physicians  prescribe  the  application  of  ice-bags  to 
the  painful  points,  cold  douches  and  dry  frictions  to  the  diseased  limb,  or 
the  filiform  douche  (Fleury),  which  constitutes  a  form  of  high-pressure 
atomizer. 

Although  these  measures  may  undoubtedly  prove  successful,  especially 
iö  robust  individuals  and  in  the  peripheral  forms  (as  is  shown  by  Lagre- 
lette's  statistics),  we  must  nevertheless,  in  a  large  number  of  cases  of 
sciatica,  avoid  all  extremes  of  temperature.  A  much  milder  plan  and  one 
that  is  applicable  to  all  cases,  consists  of  the  use  of  moist  packs  (until  the 
return  of  warmth  over  the  entire  body  and  especially  in  the  legs),  followed 
by  cool  affusions  or  half-baths  at  23°-18°  C,  with  frictions  to  the  limbs. 


b.  Spasms  and  Paralyses  of  the  Lower  Limbs. 

Spasms  (tonic  or  clonic)  of  the  lower  limbs  may  constitute  a  part 
symptom  of  central  spasmodic  neuroses  (hysteria,  epilepsy,  tetanus,  chorea, 
etc.).  At  other  times  they  are  manifested  directly  under  the  influence  of 
the  win,  or  indirectly  by  reflex  action. 

Spasm  of  the  muscles  of  the  hip  (spasmodic  contracture,  Stromeyer) 
is  a  tonic  spasm  of  the  ilio-psoas,  the  quadratus  lumborum,  and  the  adja- 
cent muscles  upon  tke  anterior  surface  of  the  thigh.  It  is  due  to  inflamma- 
tion and  neuralgia  of  the  coxo-femoral  articulation,  to  psoas  abscess,  or  to 
diseases  of  the  lumbar  segment  of  the  vertebral  column.  The  thigh  is 
then  strongly  flexed  upon  the  hip,  the  pelvis  tilted  up,  the  limb  shortened, 
active  flexion  difficult  or  impossible,  and  passive  extension  painful  and 
accompanied  by  a  deviation  of  the  body  towards  the  affected  side.  Spasm 
of  the  extensors  or  adductors  of  the  thigh  is  a  rare  affection.  The  tonic 
and  clonic  forms  are  observed  in  central  spasmodic  neuroses  and  in  neu» 
ralgia  of  the  knee-joint.  Spasm  of  the  flexors  of  the  leg  may  be  of  central 
origin  (hysteria,  spinal  affections),  or  it  may  be  secondary  to  diseases  of 
the  knee  or  muscles.  Spasms  of  the  anterior  muscles  of  the  leg  (region 
of  the  peroneal  nerve)  are  rare,  and  are  caused  by  exposure  and  over-exer- 
tion or  by  paralysis  of  the  antagonists.  Spasms  of  the  muscles  of  the 
calf  and  of  the  sole  of  the  foot  (region  of  the  tibial  nerve)  are  much  more 
frequent.  They  include  the  contractures  from  spinal  affections,  joint 
diseases,  and  paralysis  of  the  peroneal  nerve,  which  give  rise  to  talipes 
equinus.  Rapid  and  painful  tonic  spasms  of  the  calf  and  sole  of  the  foot 
are  caused  by  exertion  in  certain  occupations,  by  forced  marches,  chilling 
of  the  foot,  or  by  reflex  action,  as  in  cholera.     Schulz  has  observed  very 


246 


CLIISTCAL   TEEATISE    O^ 


N.  crnralis. 

N.  obtmratorins— 


.._.-'M.  tensor  fasciae  late.      (Ram.  N. 
glutsei  sup.) 


M.  sartorius  - 

M.  abductor  long.  - 


„..Ic, 


Jf"— — N.   tensor  fasciae  latse.      (Ram.   N. 
cruralis.) 


Ram.  N.  cruralis  pro  M.  qnadricipit.- ,feiLii^^5^  '  ~    igüsrar 

M.  cruralis w¥^^''k         ^^M 

Ram.  N.  cruralis  pro  M.  vasto  int, . .1 


— -M.  rectus  femor. 


vastus  extern. 


FiQ.  25.— Motor  points  of  anterior  region  of  thigh. 


Ram.  inf.  N.  glut.  int.  pro.  M. 
glut,   maxim. - 

Nerv,  ischiadicus 

Muse,  biceps  (long  head) 


Muse,  biceps  (short  head)- — 


Nerv,  tibialis 
Nerv,  peroneus-- 
M.  gastrocnem 

M.  soleus 


||g„.— M.  adductor  magnus. 
M.  semitendinosus. 
M.  semimembraaosus. 


"■""■*    /*v'«3H" — M-  semitendinosus. 


M.  gastrocnem.  intemoa. 


Fig.  26.— Motor  points  of  posterior  regiou  of  thigh. 


DISEASES    OF   THE    NERVOUS    SYSTEM. 


247 


violent  spasms,  commencing  in  the  soles  and  extending  to  the  dorsal  sur- 
face of  the  foot  and  to  the  calf  (region  of  the  posterior  tibial  nerve),  in 
danseuses,  after  dancing  upon  tip-toe.  They  recovered  after  treatment 
with  electricity. 

The  saltatory  spasms,  which  have  been  referred  to  on  page  115,  are 
probably  of  central  origin.  The  nature  of  the  tonic  rheumatic  spasms  of 
the  lower  limbs  attended  with  albuminuria,  which  were  described  by 
Kussmaul  (Ber.  Klin.  Wschr.,  42-44,  1871),  has  not  been  thoroughly 
determined. 


M.  peroneus  long. -.__.. 

M.  tibialis  anticus 


\ 
I 


'~-~'i 


'M }j_  peroneus, 

,  ..-.■.■.a 

<^^äL n.  gastrocnem.  extern, 

/Sil 

|v,^:--i-^ —  M.  soleus. 

■-'" —  M.  extensor  dig.  comm, 
longus. 


. .-M.  peroneus  brevis. 


-M.  soleus. 


M.  extens.  haUnc,  long,-- 


-M.  flex,  hallucis  longus. 


Bam.  N,  peron.  prof,  pro 
M.  extens.  dig.  brevis 


Mm.     interossei      pedis 
dorsales. 


-——J M.  extensor  dig.  comm. 

brevis. 

-M.  abductor  dig.  minim, 
ped. 


Fig.  27. — Motor  points  of  outer  side  of  leg. 


The  treatment  of  all  the  spasms  in  question  is  determined  by  the 
principles  which  we  have  previously  laid  down;  careful  attention  must  be 
paid  to  the  primary  disease.  Cupping  along  the  spinal  column,  galvanic 
or  faradic  treatment,  anti-spasmodics,  subcutaneous  injections  of  mor- 
phine, tenotomy,  or  orthopedic  apparatus  in  old  and  obstinate  cases,  are 
the  principal  measures  employed. 

Paralysis  of  the  crural  nerve  and  of  the  extensors  of  the  leg  which 
are  innervated  by  it,  is  observed  after  traumatism,  pressure  upon  the  lum- 
bar plexus  during  delivery,  acute  diseases,  neuritis,  progressive  muscular 
atrophy,  infantile  paralysis,  and  myelitis.     Electrical  contractility  is  al- 


248 


CLINICAL    TREATISE    ON 


most  always  affected  to  a  greater  or  less  extent.  Not  alone  is  extension 
of  the  leg  compromised  in  severe  forms,  but  the  paralysis  of  the  ilio-psoas 
muscles  also  causes  the  loss  of  the  power  of  flexion  of  the  leg  upon  the 
pelvis.  In  bilateral  forms  (after  difficult  labor)  the  patients  are  compelled 
to  remain  abed. 

Paralysis  of  the  obturator  nerve  (with  loss  of  the  power  of  adducting 
the  thigh)  and  of  the  gluteal  nerves  (loss  of  the  movements  of  abduction 
and  rotation  of  the  thigh)  is  rarely  observed,  and  only  as  a  part  symptom 
of  central  lesions  or  of  general  paralysis  after  acute  diseases. 


M.    gaetrocnemius    IntemuS' 
M.  BoleuB- 


M.  flex.  dig.  commun.  long. 


N.  tibial!» 


IL  abductor  hallucis 


Fig.  28.— Motor  points  of  inner  side  of  leg. 


Paralyses  of  the  lower  limbs  occur  most  frequently  in  the  distribution 
of  the  sciatic  nerve  and  its  branches.  The  superior  segment  of  the  sciatix3 
nerve  is  much  more  rarely  involved  than  the  lower,  which  corresponds  to 
the  peroneal  and  tibial  nerves.  These  forms  of  paralysis  are  chiefly  at- 
tributable to  rheumatic  and  traumatic  influences  (delivery,  operations, 
pelvic  tumors).  Upon  page  172,  we  have  reported  a  case  of  simultaneous 
paralysis  of  the  tibial  and  peroneal  nerves,  from  a  gunshot  wound  of  the 
sciatic  at  its  bifurcation.  The  nerves  in  question  are  also  the  seat  of  more 
or  less  extensive  paralysis  in  various  cerebral  and  spinal  lesions,  after 
febrile  diseases,  and  in  infantile  spinal  paralysis  and  progressive  muscular 
atrophy.     Paralysis  of  the  flexors  of  the  thigh  is  extremely  rare. 

Among  the  paralyses,  occurring  in  the  distribution  of  the  peroneal 


DISEASES    OF    THE    NERVOUS    SYSTEM.  249 

nerve,  that  of  the  anterior  tibial  muscle  is  characterized  by  dropping  of 
the  toes,  by  the  abduction  which  occurs  during  attempts  at  flexion,  and 
by  the  prominence  formed  by  the  extensor  proprius  pollicis.  In  paral- 
ysis of  the  peroneus  longus,  the  foot  is  adducted;  when  standing,  it 
assumes  the  position  of  talipes  valgus,  but  in  attempts  at  extension  this 
changes  to  varus,  and  is  accompanied  by  pain;  the  foot  readily  tires,  and 
i»  the  seat  of  acute  pain  in  the  external  malleolar  region.  At  a  more 
advanced  stage  the  secondary  contractions  of  the  peroneus  brevis  and 
the  extensor  communis  produce  complete  rotation  of  the  foot  outwards. 
In  paralysis  of  the  common  extensor  of  the  toes,  active  extension  of  the 
first  phalanges  is  abolished,  the  foot  is  abducted,  and  is  flexed  with  diffi- 
culty. 

Among  the  paralyses  in  the  distribution  of  the  tibial  nerve,  that  of 
the  muscles  of  the  calf  produces  what  is  known  as  talipes  cavus,  consist- 
ing of  valgus  with  forced  extension  of  the  heel,  exaggerated  excavation 
of  the  plantar  arch,  and  secondary  deformities  in  the  articulations  of  the 
foot.  Paralysis  of  the  flexors  of  the  toes  abolishes  the  power  of  flexing 
the  first  two  phalanges.  In  paralysis  of  the  interossei,  the  lateral  move- 
ments of  the  toes,  flexion  of  the  first  joint,  and  extension  of  the  last  two 
joints  of  the  toes,  are  rendered  impossible. 

The  (liag7iosls  of  these  various  motor  disturbances  is  rendered  easy  if 
we  are  able  to  exclude  primary  contracture  and  if  passive  movements 
are  preserved.  The  prognosis  depends  upon  the  etiology,  the  duration 
of  the  disease,  and  the  secondary  changes  in  the  muscles  and  joints.  The 
most  efiicient  therapeutic  measures  consist  of  galvanization  of  the  nerves, 
combined  with  faradic  stimulation  of  the  muscles,  and  rational  gymnas- 
tics and  orthopedics. 

c.   Coccygodynia. 

Krukenberg,  Nott,  Simpson,  Erichsen,  and  Scanzoni  have  applied  the 
term  coccygodynia  to  neuralgia  of  the  branches  of  the  coccygeal  plexus. 
The  disease  is  characterized  by  acute  pain  in  the  coccyx,  especially  in  the 
sitting  or  vertical  position,  the  pain  usually  radiating  into  the  perineum, 
the  vesical  region,  and  even  into  the  hips.  This  distressing  sensation 
forces  the  patient  to  sit  sideways  upon  the  edge  of  a  chair  or  to  place 
the  hand  underneath  the  buttocks  while  sitting.  Some  patients  experi- 
ence extreme  difficulty  in  walking  and  in  going  to  stool.  The  pains 
increase  upon  slight  concussion,  as  upon  coughing  and  sneezing,  and 
upon  pressure,  especially  from  below  upwards. 

Among  the  causes  of  coccygodynia,  we  may  enumerate  the  following 
conditions:  inflammation  of  the  coccyx  and  its  ligaments,  diseases  of  the 
periosteum,  caries  of  the  last  coccygeal  vertebra  (Nott),  displacement  of 
the  coccyx  in  consequence  of  muscular  contractions,  fracture  or  ankylosis, 
and  perhaps  inflammation  of  the  coccygeal  gland.  This  affection  occurs 
most  frequently  in  women  after  difficult  labors,  in  uterine  affections,  hys- 
teria, and  after  injury. 

As  regards  treatment,  Scanzoni  prescribes  leeches,  warm-baths,  com- 
presses, and  subcutaneous  injections  of  morphine.  In  Gosselin's  case 
the  neuralgia  disappeared  after  the  prolonged  use  of  an  air-cushion  (to 
avoid  pressure)  and  mild  purgatives.  Surgical  intervention  is  the  only 
resource  left  in  rebellious  and  very  painful  cases.  Nott,  of  Alabama, 
who  first  resorted  to  surgical  interference,  extirpated  the  coccyx  (Amer. 


250  CLINICAL    TREATISE    ON 

Journ.  of  Med.  Science,  III.,  1832).  Simpson  performed  subcutaneous 
section  of  the  muscles  and  ligaments  inserted  into  the  coccyx;  in  severe 
cases  he  resorted  to  excision  of  the  bone.  Seeligmueller  (Neuropath. 
Beob,,  Jena,  1873)  cured  a  coccygodynia  of  twelve  years'  standing  by  fara- 
dization (the  negative  pole  in  the  cervical  canal,  the  positive  upon  the 
sacrum).  Amann  merely  obtained  a  certain  amount  of  improvement  by 
the  employment  of  galvanization. 


Neuralgias  of  the  Joints  {Articular  Neuralgia). 

These  were  first  described  by  Brodie  (Pathol,  and  Surg.  Observ.  on 
Diseases  of  the  Joints,  London,  1818),  and  were  investigated  at  a  later 
period  by  Stromeyer  (Handb.  d.  Chir.,  1844,  and  Erfahr,  u.  Localneurosen, 
1873),  Esraarch  (Ueber  Gelenkneurosen,  1872),  Wernher  (Ueber  nerv. 
Coxalgia,  Deutsch.  Zeitschr.  f.  Chir.,  Bd.  I.,  1872),  and  O.  Berger  (Ber. 
Klin.  Wschr.,  1873,  and  Deutsch.  Zeitschr.  f.  prak.  Med.,  1874). 

Ruedinger  (Die  Gelenksnerven  des  menschlichen  Koerpers.  1867)  discovered  that 
a  large  number  of  nerve-fibres  are  distributed  to  the  ligaments,  fibrous  capsule,  and 
especially  to  the  synovial  membrane  of  the  large  and  small  joints  of  the  limbs  (and 
also  to  the  vertebral  articulations).  The  articular  nerves  originate  partly  from  the 
spinal,  partly  from  the  sympathetic  system. 

The  abundance  of  nerves  in  the  larger  and  smaller  joints  and  in  the 
surrounding  skin  enables  us  to  understand  why  these  parts  are  the  seat 
of  irritative  phenomena,  which  Esmarch  and  especially  Berger  regard  as 
true  neuralgias. 

Among  the  etiological  factors,  the  chief  importance  must  be  attached 
to  a  neuropathic  condition,  which  is  either  congenital  or  acquired  by  the 
habits  of  life  and  diet,  and  in  consequence  of  anaemia  and  hysteria.  It 
is  for  this  reason  that  women  and  girls  suffer  so  frequently  from  various 
forms  of  articular  neuralgia.  Upon  several  occasions,  also,  I  have  ob- 
served neuralgia  of  the  shoulder,  elbow,  and  knee,  in  young  boys  who 
have  been  addicted  to  masturbation  for  a  long  time.  The  exciting  causes 
include  emotional  excitement,  traumatism,  contusions,  pressure  upon  the 
joints,  fatigue,  and  more  rarely  rheumatic  influences.  At  times  articular 
neuralgias  are  induced  by  gastric  disturbances,  irritations  of  the  sexual 
apparatus  (the  abdominal  sympathetic  has  numerous  relations  with  the 
sacro-coccygeal  plexus),  and,  finally,  by  acute  diseases  and  central  affec- 
tions (hemiplegia  and  ataxia,  according  to  Berger). 

The  symptoms  develop  gradually,  but  they  may  also  appear  suddenly. 
Pain  is  the  chief  symptom;  it  appears  in  certain  joints  with  periodical 
exacerbations,  radiates  into  the  surrounding  parts,  and  usually  increases 
towards  evening  and  diminishes  at  night.  The  pain  sometimes  disappears 
if  the  patient  immediately  begins  to  walk.  Menstruation  may  either 
diminish  or  increase  the  neuralgic  phenomena. 

Examination  of  the  affected  joint  does  not  reveal  any  especial  changes. 
Certain  signs,  which  are  found  in  the  majority  of  neuralgias,  are  never- 
theless present.  These  include  the  puncta  dolorosa,  for  the  hip,  between 
the  trochanter  major  and  ischium,  and  in  the  vicinity  of  the  anterior 
superior  spinous  process  of  the  ilium;  for  the  knee,  upon  the  inner  border 
of  the  patella,  in  the  popliteal  space  and  above  the  head  of  the  fibula;  for 


DISEASES    OF   THE    NERVOUS    SYSTEM.  251 

the  ankle-joint,  behind  the  two  malleoli;  for  the  shoulder,  over  the  nerves 
of  the  brachial  plexus  and  in  the  axillary  space;  for  the  elbow,  over  the 
epitrochlea  and  head  of  the  radius;  for  the  wrist,  over  the  styloid  process 
of  the  ulna.  According  to  my  experience,  certain  forms  of  rachialgia  and 
so-called  spinal  irritation  should  be  attributed  to  neuralgias  of  the  verte- 
bral articulations.  They  are  characterized  by  lancinating  or  pricking 
pains,  which  recur  periodically,  and  exacerbate  either  spontaneously  or 
after  excitement,  effort,  or  forced  movements.  The  pains  extend  along 
the  vertebral  column,  with  painful  points  over  the  spinous  and  transverse 
processes,  between  the  shoulders  or  upon  the  scapulse,  and  are  accompa- 
nied by  circumscribed  cutaneous  hyperaesthesia,  local  sensations  of  heat 
or  cold,  and  sometimes  by  other  arthralgias.  We  rarely  find  other  posi- 
tive signs  of  hysteria  in  these  cases.  Superficial  pressure  over  certain 
portions  of  the  dorsal  region  do  not  give  rise,  as  in  hysteria,  to  the  char- 
acteristic attacks  which  are  accompanied  by  sensations  of  dread,  constric- 
tion of  the  neck  or  epigastrium,  etc. 

In  addition  to  the  puncta  dolorosa,  articular  neuralgias  are  accompa- 
nied by  diffuse  hypergesthesia  of  the  surrounding  integument  (Brodie), 
and,  in  cases  of  long  duration,  by  irradiated  anaesthesia  and  parjesthesia 
(formication,  burning).  The  vaso-motor  disorders  consist  of  periodical 
alterations  in  the  color  and  temperature  of  the  skin,  diffuse  oedema  around 
the  joint  from  time  to  time,  considerable  swelling,  and  urticaria  (Brodie). 
Wernher  and  others  have  published  cases  of  emaciation  of  the  limb  and 
atrophy  of  the  muscles  around  the  articulation.  The  motor  disorders  in- 
clude muscular  spasms  (frequently  combined  with  immobility  of  the  limb 
in  extension  or  pseudo-ankylosis,  which  disappears  under  the  influence 
of  chloroform)  and  paralytic  weakness,  even  in  the  intervals  between  the 
neuralgic  attacks. 

Among  eighty  cases  of  articular  neuroses  collected  by  Esmarch,  thirty- 
eight  occurred  in  the  knee,  eighteen  in  the  hip,  eight  in  the  wrist,  seven 
in  the  ankle,  four  in  the  shoulder  and  elbow,  and  one  in  the  fingers. 
This  leaves  out  of  consideration  the  neuralgias  of  the  vertebral  articula- 
tions which,  in  our  opinion,  are  of  frequent  occurrence. 

The  diagnosis  may  be  surrounded  with  great  diflRculties  from  the  fact 
that  articular  inflammations  or  caries  sometimes  present  at  the  outset  all 
the  appearances  of  neuralgic  arthritis.  In  such  cases  continued  observa- 
tion will  enable  us  to  recognize  the  true  character  of  the  affection.  A 
marked  neuropathic  condition  and  positive  signs  of  hysteria  are  of  great 
assistance  in  forming  a  diagnosis.  But  the  chief  sign,  as  Esmarch  has 
shown,  is  the  striking  disproportion  between  the  intensity  and  persistence 
of  the  affection  and  the  slight  importance  of  the  articular  changes.  The 
following  phenomena  speak  in  favor  of  articular  neuralgia:  paroxysms  of 
pain,  which  usually  grow  milder  during  the  night,  puncta  dolorosa,  cuta- 
neous hyperjEsthesia,  vaso-motor  disorders,  slight  pain  upon  bringing  the 
articular  extremities  in  contact,  slight  emaciation  even  after  absolute  rest 
for  several  months.  In  articular  inflammations,  on  the  other  hand,  there 
is  persistent  tumefaction,  spasmodic  flexion  of  the  limb,  and  increase  of 
the  pain  upon  pressing  the  ends  of  the  joints;  rest  and  the  use  of  fixation 
apparatus  exert  a  favorable  influence.  Careful  examination  will  enable 
us  to  avoid  the  serious  diagnostic  and  therapeutic  mistake  which  was 
committed  in  a  case  reported  by  Brodie.  For  a  relapsing  neuralgia  of 
the  knee,  the  unfortunate  patient  was  subjected  to  amputation  of  the 
thigh,  then  to  section  of  the  sciatic  nerve,  and,  finally,  to  disarticulation 
of  the  hip-joint. 


252    CLINICAL  TREATISE  ON  DISEASES  OF  THE  NERVOUS  SYSTEM. 

The  prognosis  is  favorable  in  young  patients  who  suffer  from  simple 
nervousness;  it  is  more  doubtful  in  old  and  obstinate  forms  of  hysteria. 
In  the  treatment  we  may  employ  cool  affusions  and  douches  to  the  joint, 
followed  by  massage  and  passive  movements  (Esmarch),  and  may  also 
apply  the  faradic  brush  or  galvanize  the  joint.  Mountain  air,  sea-baths, 
mild  hydrotherapeutics,  simple  gymnastic  exercises,  the  administration  of 
arsenic,  and  an  appropriate  mca-al  treatment,  also  furnish  good  results. 


CLASS    X. 
VASO-MOTOR  AND  TROPHIC  NEUROSES. 


CHAPTER  L. 
Vaso-motor  ajto  Trophic  Disorders. 

Vaso-motor  and  trophic  neuroses  form  the  last  chapter  in  our  study 
of  the  diseases  of  the  nervous  system.  The  vaso-motor  disorders  which 
occur  in  cerebral  and  spinal  affections,  in  hysteria,  epilepsy,  and  peripheral 
traumatisms,  have  been  previously  discussed. 

We  have  also  referred  to  the  fact  that  the  latest  experimental  investi- 
gations of  Goltz  (Pflueg.  Arch.,  Bd.  IX.,  1874)  and  Vulpian  (Arch,  de 
Physiol.),  upon  the  vaso-dilator  nerves,  have  led  to  radical  modifications 
of  the  views  hitherto  entertained.  According  to  Goltz,  vascular  dilatation 
and  elevation  of  temperature  are  not  attributable  to  paralysis  of  the  vaso- 
motor nerves,  but  to  an  active  process,  viz.,  to  functional  over-stimulation 
of  the  vaso-dilator  nerves.  The  vaso-dilator  fibres  of  the  nerves  proceed 
directly  from  the  cord  or  may  be  brought  into  play  by  reflex  means,  from 
irritation  of  the  centripetal  fibres  of  other  nerves.  These  experimental 
data  require  confirmation  and  elucidation  by  new  investigations.  Never- 
theless they  afford  a  more  satisfactory  explanation  of  certain  contradic- 
tory symptoms  in  hysteria  (vide  page  31)  and  in  Basedow's  disease. 

The  theory  of  the  existence  of  trophic  nerves  and  the  disorders  depend- 
ent upon  them,  is  still  under  discussion,  and  its  solution  will,  perhaps, 
occupy  a  long  time.  According  to  some  authors,  the  vaso-motor  ele- 
ments contained  in  the  mixed  nerve-trunks  become  paralyzed  when  cen- 
tral innervation  is  arrested,  and  thus  give  rise  to  retardation  of  the  circu- 
lation and  passive  hyperemia,  with  disturbances  in  the  nutrition  of  the 
muscles.  Nevertheless,  observation  teaches  us  that  motor  paralysis  may 
continue  for  a  long  time  with  marked  functional  and  circulatory  disturb- 
ances, but  without  any  appreciable  alteration  of  nutrition.  Conyba  and 
Charcot  attribute  the  trophic  disorders  occurring  after  injuries  to  the 
nerves  to  a  neuritis,  and  the  same  interpretation  has  been  more  recently 
applied  by  Friedreich  to  the  pathogeny  of  progressive  muscular  atrophy, 
which  he  attributes  to  an  inflammatory  process  in  the  muscles  and  an 
intra-muscular  neuritis  that  is  propagated  along  the  nerve-trunks  and 
roots  to  the  spinal  cord.  We  have  analyzed  and  refuted  thfe  theory  in 
the  chapter  on  progressive  muscular  atrophy  (pages  17-19). 

The  view  that  the  principal  source  of  trophic  disorders  is  situated  in 
the  spinal  cord,  is  gaining  ground  more  and  more.     As  we  previously 


254  CLINICAL   TREATISE    ON 

showed,  a  large  number  of  clinical  and  anatomical  observations  have 
proven  that  in  central  myelitis,  whether  primary  or  secondary,  and  in 
bulbar  foyers,  in  cerebro-spinal  sclerosis,  in  sclerosis  of  the  posterior  col- 
umns, in  symmetrical  sclerosis  of  the  lateral  columns,  in  meningo-myelitis 
and  hypertrophic  pachymeningitis,  in  a  word,  in  all  lesions  of  the  anterior 
gray  columns  of  the  cord,  marked  trophic  disturbances  occur  in  the  mus- 
cles, joints,  and  skiij.  Secondary  sclerosis  of  the  lateral  columns  in  cere- 
bral apoplexy,  when  it  is  propagated  forwards,  and  central  myelitis  with 
inflammatory  degeneration  of  the  anterior  horns,  give  rise  to  progressive 
muscular  atrophy.  The  multipolar  cells  of  the  anterior  horns  of  gray 
matter  contain,  therefore,  important  trophic  centres  (Charcot).  But  the 
trophic  influence  of  the  cord  cap  only  act  upon  the  peripheral  parts  by 
passing  along  certain  paths  of  transmission,  and  solutions  of  continuity 
in  these  trophic  conductors  in  traumatic  lesions  of  the  peripheral  nerve- 
trunks  will  produce  considerable  disturbances  in  the  nutrition  of  the  mus- 
cles and  other  tissues. 

In  the  following  section  we  shall  discuss  those  diseases  of  the  vaso- 
motor and  trophic  nerves  which,  thanks  to  the  discoveries  of  pathological 
anatomy,  are  better  understood  at  the  present  time.  We  refer,  for  fur- 
ther details,  to  the  works  of  Eulenburg  and  Guttmann  upon  the  pathology 
of  the  sympathetic  system  (Berlin,  1873). 


1.    MIGRAINE    (hEMICEANIA). 

This  term  refers  to  a  paroxysmal  headache  which  was  known  to  the 
older  physicians  (Tissot,  J.  Frank,  etc.),  but  was  not  distinguished  by 
them  from  prosopalgia.  Romberg  and  Leubuscher  were  the  first  to  rec- 
ognize the  fact  that  migraine  is  a  cerebral  neuralgia.  Nearly  twenty 
years  ago.  Du  Bois-Reymond  (Arch.  f.  Anat.  u.  Phys.,  18G0)  observed 
certain  phenomena  in  his  own  person  (the  temporal  artery  forming  a  hard 
cord  upon  the  affected  side,  anjBmia  of  the  face,  sinking  in  of  the  eye,  dila- 
tation of  the  pupil,  and,  finally,  redness  of  the  ear),  which  led  him  to  be- 
lieve that  migraine  consists  of  a  condition  of  tetanus  of  the  vascular  mus- 
cles on  the  affected  side  or  of  tetanus  of  the  vessels  in  the  distribution  of 
the  cervical  sympathetic  (sympathico-tonic  migraine). 

The  spasm  of  the  vascular  muscles,  and  the  compression  of  the  sensory 
nerves  which  traverse  the  vessels,  were  regarded  as  the  immediate  causes 
of  the  pain,  as  they  are  in  cramps  in  the  calves,  colic,  and  labor  pains. 
According  to  Eulenburg  and  Landois,  the  fluctuations  in  the  current  of 
arterial  blood,  the  temporary  hyperaemia  and  anemia  of  one-half  of  the 
head,  will  suffice  to  irritate  the  sensory  nerves  of  the  scalp,  pericranium, 
cranial  meninges,  or  sensitive  parts  of  the  brain,  and  to  produce  the 
paroxysms  of  pain. 

According  to  Moellendorf  (Virch.  Arch.,  Jan.,  1868),  migraine  is  due  to 
a  lack  of  energy  (occurring  either  with  or  vpithout  periodical  manifesta- 
tions) in  the  vaso-motor  nerves  of  one  of  the  carotids,  with  secondary  re- 
laxation of  the  vessel  and  arterial  fluxion  to  the  brain.  According  to 
Goltz's  experiments,  however,  there  is  active  irritation  of  the  vaso-dilator 
nerves.  The  secondary  symptoms  include  hyperresthesja  of  the  senses 
and  of  the  scalp,  nausea  and  vomiting.  Dimness  of  vision,  difficulty  in 
the  movements  of  the  eyeballs,  and  dulled  sensibility,  are  observed 
among  the  symptoms  of  compression.  In  support  of  his  theory,  Moellen- 
dorf refers  to  the  entire  suppression  of  the  pain  which  follows  compres- 


DISEASES    OF   THE    NERVOUS    SYSTEM.  255 

sion  of  the  carotid  on  the  affected  side,  to  the  return  of  the  pain  when 
the  compression  ceases,  and  its  increase  by  compression  of  the  carotid  on 
the  healthy  side;  to  the  dilatation  of  the  central  vessels  which  was  ob- 
served in  one  case  with  the  ophthalmoscope  (scarlet  redness  of  the  fun- 
dus of  the  eye,  dilatation  of  the  central  retinal  artery  and  vein,  the  latter 
being  knotted  and  sinuous),  the  eye  upon  the  healthy  side  being  in  a 
normal  condition;  finally,  to  the  marked  slowness  of  the  pulse,  the  small 
size  and  contraction  of  the  radial  arteries  contrasting  with  the  ample 
pulsation  in  the  carotid  and  temporal  arteries  (sympathico-paralytic 
migraine). 

Two  of  my  cases  of  migraine  were  very  characteristic.  In  one  of  these  patients, 
whom  I  examined  several  times  at  the  close  of  the  attacks,  the  seat  of  the  affection 
was  readily  recognized  by  the  bright  redness  of  the  left  cheek  and  ear.  In  the  second 
case  I  cx)uld  note  the  transition  from  the  first  stage,  that  of  vascular  spasm,  to  the 
second  or  angio-paralytic  period.  This  occurred  in  a  young  hysterical  girl  in  whom 
the  migraine  began  with  a  sensation  of  cold  in  the  fingers  and  toes  of  both  sides  (the 
tips  of  the  fingers  became  cold  in  the  intense  heat  of  midsummer).  In  a  little  whüe 
the  face  became  pale  and  the  pulse  fell  to  sixty.  After  the  paroxysm,  the  hands  be- 
came very  warm  and  perspired  freely,  and  the  cheeks  reddened,  especially  on  the 
right  side.     The  pupil  of  the  affected  side  was  dilated. 

The  vaso-motor  cephalalgia  of  Eulenburg  (with  fronto-temporal  pain, 
redness  and  heat  of  the  face  and  ear)  is  probably  merely  a  variety  of  mi- 
graine attended  with  vascular  spasm.  The  latter  is  not  a  neuralgia  of 
the  brain  or  trigeminus,  but  a  disease  of  the  cervical  or  cephalic  portion 
of  the  sympathetic  or  of  the  vaso-motor  centres  themselves.  The  slow 
pulse  observed  in  the  angio-paralytic  form  must  be  attributed  (according 
to  Landois'  experiments  upon  artificial  cerebral  hypersemia)  to  irritation 
of  the  medulla  oblongata  and  pneumogastric  nerves.  This  variety  of 
migraine  also  presents  the  signs  of  paralysis  of  the  sympathetic.  Enter- 
algia  and  diarrhoea  are  sometimes  observed  as  complications,  and  are  due 
to  paralysis  of  the  abdominal  vaso-motor  nerves.  In  the  tonic  form, 
ptosis  and  myosis  (Berger)  sometimes  occur,  probably  from  paralysis  of 
the  muscular  fibres  of  Mueller,  which  are  innervated  by  the  sympathetic 
and  are  distributed  to  the  orbicularis  palpebraerum.  The  salivation  has 
been  attributed  by  Gruetzner  to  irritation  of  the  salivary  centre  in  the 
medulla  oblongata. 

Migraine  occurs  chiefly  in  women,  who  present,  for  the  most  part,  a 
morbid  excitability  due  to  anaemia  or  hysteria.  It  is  a  very  distressing 
affection,  and  is  often  accompanied  by  vomiting.  I  have  observed  it  in 
girls  ten  to  twelve  years  of  age,  whose  mothers  also  suffered  from 
migraine  or  from  extreme  nervousness.  The  disease  is  also  frequent  in 
men  under  similar  conditions.  Migraine  disappears  at  the  menopause, 
when  the  vascular  system  becomes  calmer. 

Treatment. — In  the  periodical  forms:  quinine  and  Fowler's  solution 
(in  increasing  doses);  in  irregular  forms:  valerianate  of  caffeine^  paulinia 
sorbilis  (two  to  four  grains  per  diem),  large  doses  of  bromide  of  potas- 
sium; in  chlorotic  patients:  ferruginous  preparations,  mineral  waters, 
country  air.  Nitrite  of  amyl  has  been  recently  recommended  in  migraine 
attended  with  vascular  spasm  (the  patient  inhales  two  to  five  drops). 
Filehne  (Pflueger's  Arch.,  Bd.  IX..,  1874)  believes  that  this  drug  espe- 
cially paralyzes  the  vaso-motor  centres  and  the  origin  of  the  pneumogas- 
trics  (it  is  attended  with  considerable  slowing  of  the  pulse).  Eulenburg 
and  Berger  highly  recommend  the  extract  of  ergot  (internally  or  subcu- 


256  CLimCAL    TREATISE    OT^" 

taneously)  in  angio-paralytic  migraine.  According  to  my  observations, 
these  various  drugs  do  not  possess  a  permanent  influence  upon  irritation 
of  the  vaso-motor  apparatus.  Better  results  are  obtained  by  stimulating 
the  energy  of  the  vascular  nerve-centres  by  means  of  hydrotherapeutics, 
sea-baths,  mountain  air,  and  rational  and  moderate  gymnastics.  Electro- 
therapeutics also  prove  successful  in  some  cases.  Frommhold  employs 
the  primary  induced  current,  the  positive  pole  being  applied  to  the  neck, 
the  neo-ative  pole  to  the  orbit,  forehead,  temple  or  top  of  the  sagittal 
suture,  for  three  to  five  minutes.  Hoist,  with  more  propriety,  resorts  to 
galvanic  treatment,  with  a  large  electrode  over  the  cervical  sympathetic 
at  the  outer  border  of  the  sterno-mastoid  muscle,  and  the  other  electrode 
in  the  palm  of  the  hand.  In  the  spasmodic  form,  the  anode  is  placed 
over  the  sympathetic  in  order  to  diminish  the  excitability.  In  the  varie- 
ties which  are  attended  with  depression,  the  cathode  is  placed  over  the 
sympathetic,  and,  in  order  to  obtain  increased  stimulation,  it  is  provided 
with  a  commutator. 


2.    UNILATERAL   ATROPHY    OF   THE    PACE    (FACIAL   HEMIATROPHY). 

This  peculiar  affection,  which  is  characterized  by  atrophy  of  the  soft 
parts,  bones,  and  cartilages  upon  one-half  of  the  face,  has  been  called 
prosopodysmorphia  by  Bergson,  nervous  atrophy  of  the  face  by  Samuel 
and  Baerwinkel,  progressive  laminar  aplasia  of  the  face  by  Lande,  and 
progressive  facial  hemiatrophy  by  Eulenburg. 

The  disease  begins  with  the  appearance  of  white  spots  upon  one-half 
of  the  face,  followed,  in  a  short  time,  by  extreme  rarefaction  of  the  sub- 
cutaneous adipose  tissue  and  atrophy  of  the  different  layers  of  the  skin, 
with  circumscribed  discoloration  of  the  hairs  or  alopecia  (head,  beard  and 
eyebrows),  and  diminution  or  complete  abolition  of  the  cutaneous  secre- 
tions, especially  of  the  sebum.  In  very  marked  forms,  the  skin  is  rough, 
puffy,  or  squamous;  its  sensibility  is  sometimes  increased,  and  it  is  the 
seat  of  neuralgic  sensations  and  circumscribed  parf^sthesias.  For  a  long 
time  the  muscles  present  no  appreciable  change  in  volume  or  in  the  elec- 
trical reactions.  But,  in  the  very  advanced  forms,  the  face  is  often 
drawn  slightly  away  from  the  atrophied  side,  and  the  masseters,  the  mus- 
cular tissue  of  the  lips  (Hueter,  Lande,  Hitzig,  Guttmann),  of  the  tongue, 
and  the  pillars  of  the  soft  palate  are  found  atrophied.  Excitement  some- 
times produces  redness  of  the  affected  cheek,  but,  in  other  cases,  this 
phenomenon  is  not  produced.  Finally,  extreme  atrophy  also  occurs  in 
the  osseous  and  cartilaginous  skeleton  of  the  face  (nasal  cartilages,  malar 
bone,  superior  and  inferior  maxillae),  with  displacement  of  the  teeth. 
Sight  remains  intact. 

The  following  etiological  conditions  have  been  noted:  acute  exanthe- 
mata (diphtheria,  Emminghaus),  exposure,  traumatism,  syphilis  (Graefe's 
case  with  paralysis  of  the  left  oculo-motor  externus  arid  trigeminus), 
epileptiform  convulsions  (M.  Meyer,  Brunner),  cerebral  affections  with 
hemiplegia  (Parry),  with  neuralgia  of  the  trigeminus  and  keratomalacia 
(Pissling),  symptoms  of  irritation  of  the  cord  (personal  observation, 
Wien.  Med.  Presse,  1868).  Unilateral  atrophy  of  the  face  is  much  more 
frequent  in  females,  and  the  largest  number  of  cases  occur  in  early  life 
■until  the  age  of  twenty.  The  disease  manifests  a  predilection  for  the 
left  side  of  the  face. 


DISEASES    OF    THE    NERVOUS    SYSTEM.  257 

In  a  case  published  by  Brunner  (Petersb.  Med.  Zschr.,  Bd.  II.,  1871),  a  woman 
twenty-seven  years  of  age,  who  had  previously  suffered  from  epileptiform  attacks, 
was  affected  with  left  facial  atrophy.  The  brows  and  hair  were  blanched,  and  yel- 
lowish-gray spots  formed,  which  then  changed  to  brown.  She  suffered  from  pains  in 
the  left  cheek  and  eye,  which  darted  into  the  neck  and  thorax  as  far  as  the  epigastric 
region.  Upon  examining  the  patient,  complete  atrophy  of  the  left  frontal  and  tem- 
poral muscles  was  noted,  and  less  pronounced  atrophy  in  the  muscles  of  the  ala  nasi 
zygomatic  arch  and  lips.  The  faradic  and  galvanic  contractilitj^  and  the  electro-mus- 
cular sensibility  were  normal,  and  the  stimulus  of  the  will  was  readily  transmitted  to 
those  fibres  of  the  facial  muscles  which  were  still  intact. 

In  addition,  the  left  pupil  was  dilated  and  reacted  slowly  to  light,  there  was  a 
slight  degree  of  exophthalmia,  and  the  temperature  was  lowered  upon  the  affected 
side  of  the  face.  The  secretion  of  perspiration  was  suppressed,  and  the  cardiac  im- 
pulses were  irregular  and  usually  accelerated.  Galvanization  of  the  sympathetic  pro- 
duced immediate  slowing  of  the  heart's  action  and  slight  dilatation  of  the  pupil;  the 
atrophied  half  of  the  face  then  became  bright  red,  and  covered  with  profuse  perspira- 
tion. Epileptic  attacks  appeared  after  the  employment  of  weak  induction  currents, 
but  no  convulsions  could  be  produced  by  the  use  of  the  constant  current. 

In  a  case  of  atrophy  of  the  left  side  of  the  face  reported  by  Guttmann  (Arch.  f. 
Psych.,  Bd.  I.,  1,868),  galvanization  produced  redness  of  the  affected  side  which  per- 
sisted for  an  hour. 

According  to  Brunner,  his  case  was  due  to  permanent  irritation  of 
the  sympathetic  (following  an  inflammatory  process  or  a  tumor),  such  as 
was  obtained  in  the  experiments  of  Biffi  and  Claude  Bernard.  In  the 
latter  investigations,  galvanization  of  the  cervical  sympathetic,  after  sec- 
tion of  the  nerve,  produced  dilatation  and  sluggishness  of  the  pupil,  ex- 
ophthalmia,  fall  of  temperature,  and  pallor  of  the  conjunctiva,  ear,  and 
nose.  When  the  galvanization  was  interrupted,  the  reverse  symptoms, 
due  to  section  of  the  sympathetic,  made  their  appearance.  In  the  com- 
plete absence  of  anatomical  data,  which  will  enable  us  to  explain  unilat- 
eral atrophy  of  the  face,  we  are  compelled  to  resort  to  mere  hypotheses. 
Certain  authors  consider  it  an  affection  of  the  vaso-motor  nerves  of  the 
face  which  are  contained  in  the  branches  of  the  trigeminus.  Others 
regard  it  as  due  to  a  lesion  of  the  trophic  fibres  or  of  the  cervical  sympa- 
thetic, traumatic  lesions  of  which  have  given  rise  to  a  slight  amount  of 
facial  atrophy.  In  one  case  of  facial  atrophy,  limited  to  the  distribution 
of  the  infra-orbital  nerve,  Baerwinkel  diagnosticated  disease  of  the 
spheno-palatine  ganglion.  It  is  not  unreasonable  to  suspect  a  neuritis  of 
the  facial  nerves  corresponding  to  the  atrophied  parts. 

The  prognosis  is  unfavorable,  as  there  is  no  hope  of  a  cessation  of  the 
disease  except  from  spontaneous  arrest  of  the  atrophy.  Medicinal,  hy- 
drotherapeutiCj  and  electrical  treatment  have  hitherto  proved  useless. 


3.  Basedow's  disease. 

This  symptomatic  triad  (cardiac  irritation,  goitre,  and  exophthalmia) 
had  been  recognized  by  Stokes,  but  its  distinct  character  was  onl^^  estab- 
lished by  Graves  (1835)  and  Basedow. 

During  the  last  twenty  years  it  has  been  observed  more  frequently 
and  carefully.  The  first  pathognomonic  sign  of  the  disease  is  usually  in- 
tense cardiac  irritation,  appearing  at  first  under  the  influence  of  exciting 
causes,  and  then  in  a  condition  of  repose.  It  is  characterized  by  acceler- 
ation of  the  pulse  (120-160  per  minute),  irregularity  of  the  heart,  strong 
pulsation  and  "bruit"  in  the  carotids,  in  the  usually  dilated  vessels  of  the 
thymoid  gland,  and  often  also  in  the  abdominal  aorta.  Physical  explora- 
VOL.  11.-17 


258  CLINICAL    TKEATISE    ON 

tion  of  the  heart  frequently  reveals  nothing  abnormal.  At  other  times 
a  systolic  murmur  and  cardiac  hypertrophy  are  observed  after  the  disease 
has  lasted  for  a  certain  length  of  time. 

Enlargement  of  the  thyroid  gland  makes  its  appearance  after  the  lapse 
of  several  weeks  and  months.  Only  one  of  the  lobes  is  usually  enlarged, 
and  it  is  sometimes  traversed  by  arteries  which  give  rise  to  a  blowing 
murmur.  After  the  lapse  of  several  years  it  assumes  a  harder  consistence 
and  is  lifted  rhythmically  by  the  pulsation  of  its  vessels.  Either  at  the 
same  time,  or  a  little  sooner  or  later,  both  eyes,  or  at  times  only  one,  be- 
come more  and  more  prominent,  and  finally  assume  the  peculiar  fixed  look 
characteristic  of  a  bull's  eye.  The  palpebral  fissure  is  widely  opened, 
closure  of  the  lids  is  infrequent  and  incomplete,  and,  as  Graefe  first 
showed,  the  upper  lid  takes  but  little  part  in  the  movements  of  elevation 
and  depression  of  the  eyeball.  Stellwag  observed  abolition  of  the  lateral 
movements  of  both  eyes  with  preservation  of  the  convergence  of  the  optic 
axes  (Wien.  Med.  Jahrb.,  Bd.  XVII.,  1869);  O.  Becker  noticed,  as  a  new 
symptom,  spontaneous  arterial  pulsations  in  the  retina  (Wien.  Med. 
Wschr.,  1873).  In  many  cases  the  cornea  loses  its  sensibility  and  its  sur- 
face becomes  dry  and  opaque.  Graefe  has  seen  ulcerations  of  the  eye  in 
fourteen  cases  (Ber.  Klin.  Wschr.,  Aug.,  1867).  The  pupils  are  some- 
times dilated,  sometimes  contracted  or  normal.  The  conjunctiva  is  red, 
and  Chemosis  is  observed  at  times;  the  secretion  of  tears  is  often  very 
abundant.  By  means  of  the  ophthalmoscope,  Graefe  has  found  in  some 
cases  dilatation  and  sinuosity  of  the  retinal  veins. 

The  attendant  symptoms  of  exophthalmic  goitre  consist  of  paresis  of 
the  upper  lid,  partial  paralysis  of  the  face,  and  double  paralysis  of  the 
motor-oculi  externus  (Stellwag).  The  following  sensory  and  vaso-motor 
disorders  have  been  observed:  partial  anaesthesia  or  neuralgic  pains  in 
the  distribution  of  the  trigeminus  ;  circumscribed  vascular  dilatations 
upon  the  integument  (production  of  erythema  vipon  contact  with  the 
scalp,  "  taches  cerebrales"  of  Trousseau),  unilateral  or  bilateral,  and  some- 
times recurring  paroxysmally  (Stellwag);  redness  of  one-half  of  the  face, 
with  abnormal  pallor  of  the  other  side;  elevation  of  temperature  (Teisier, 
Cheadle,  Eulenburg,  Guttmann),  with  a  sensation  of  heat  and  hypersecre- 
tion of  sweat;  oedematous  swelling  of  the  lids,  conjunctiva,  lips,  or  integ- 
ument of  the  face;  in  one  of  Stellwag's  patients  there  was  swelling  of  the 
entire  cervical  region,  and  periodical  attacks  of  asthma.  Geigel,  Solbrig, 
and  Andrews  have  observed  ps3'chical  disturbances  (exaltation,  melancho- 
lia, and  even  mania),  which  diminished  in  intensity  as  the  primary  affec- 
tion improved. 

The  symptomatology  of  exophthalmic  goitre  may  be  varied  by  the  ab- 
sence of  one  or  the  other  of  the  clinical  signs.  Thus,  among  fifty-eight 
cases  collected  by  Busch  (Lehrb.  d.  Herzkrankh.,  1868),  the  cardiac  phe- 
nomena were  absent  three  times,  and  goitre  four  times.  In  Prael's  and 
Fischer's  cases,  Basedow's  disease  was  limited  to  a  double  exophthalmos. 
But  the  diagnosis  was  confirmed  by  the  want  of  harmony  between  the 
movements  of  the  eyes  and  those  of  the  lids,  and  by  other  general  phe- 
nomena. 

The  anatomical  examinations  which  were  made  in  a  certain  number  of 
cases  have  revealed,  as  local  lesions,  a  serous  infiltration  or  proliferation 
of  the  retro-ocular  adipose  tissue.  Naumann  found  atheromatous  degen- 
eration of  the  ophthalmic  artery;  Recklinghausen  and  Schoch,  fatty  de- 
generation of  the  ocular  muscles.  In  Schnitzler's  case  (Med.  Halle,  1864) 
Rokitansky  found  the  inner  wall  of  the  orbital  cavity,  formed  by  the  eth- 


DISEASES    OF    THE    NERVOUS    SYSTEM.  259 

moid,  of  unusual  firmness,  convex,  projecting  into  the  orbital  cavity,  and 
narrowing  it  very  markedly  behind;  the  ethmoidal  sinuses  were  enormous- 
ly dilated,  gorged  with  muco-pus,  and  their  walls  very  much  thickened. 
In  many  cases  the  thyroid  gland  presented  hyperjtmic  swelling  and  vas- 
cular hyperplasia  or  dilatation.  The  heart  was  often  free  of  abnormali- 
ties. But,  at  other  times,  it  presented  waxy  degeneration  of  the  cardiac 
muscles,  dilatation  or  hypertrophy,  valvular  lesions,  or  atheroma  of  the 
large  vessels  (of  the  ascending  aorta,  in  Prael's  case). 

The  following  changes  have  been  observed  in  the  nervous  system  : 
spots  of  softening  at  the  base  of  the  anterior  cerebral  lobe,  softening  of  the 
optic  thalamus,  tubercula  quadrigemina  and  cerebellum  (Prael's  observa- 
tion, lesions  probably  of  embolic  origin),  and  various  changes  in  the 
sympathetic  nerves.  Trousseau  and  Lancereaux,  and  more  recently 
Knight,  have  found  an  increase  of  the  connective  tissue,  and  atrophy  and 
diminution  of  the  nerve-cells  in  the  cervical  sympathetic.  Beveridge  ob- 
served thickening  and  tubercular  degeneration  of  the  sympathetic  system, 
and  of  the  fibres  supplying  the  inferior  thyroid  and  vertebral  arteries;  in 
addition,  hypertrophy  and  induration  of  the  middle  and  inferior  cervical 
ganglia,  which  were  filled  with  a  granular  mass  and  looked  like  tuberculous 
lymphatic  glands.  In  Moore's  case  the  inferior  cervical  ganglion  was 
almost  entirely  destroyed  and  replaced  by  connective  and  adipose  tissue. 
Recklinghausen  and  Biermer  found  atrophy,  Virchow,  on  the  other  hand, 
hypertrophy  and  interstitial  thickening  of  the  cervical  sympathetic.  In 
Geigel's  case  the  cervical  sympathetic  on  both  sides  was  surrounded  by  a 
sheath  of  thickened,  fatty  connective  tissue,  but  no  change  was  discovered 
with  the  microscope  in  the  nerves  themselves  and  in  the  ganglia,  apart 
from  the  intense  brown  pigmentation  of  the  latter.  In  addition,  the  cen- 
tral canal  of  the  spinal  cord  was  obliterated,  and  the  adjacent  parts  of  the 
cord  presented  an  increased  consistence,  with  slight  proliferation  of  the 
neuroglia  and  marked  fulness  of  the  capillaries.  On  the  other  hand,  the 
microscope  showed  no  changes  in  the  sympathetic  system  in  cases  pub- 
lished by  Paul,  Fournier,  Ollivier,  Rabejac,  and  Wilks. 

The  etiological  factors  ■whieb  are  regarded  as  occurring  most  frequently  are  intense 
psychical  excitement  and  physical  or  mental  over-exertion.  Bouillaud  saw  the  dis- 
ease develop  under  the  influence  of  onanism,  and  Graefe  found  it  attain  its  maxi- 
mum of  intens  ty  within  a  few  days  after  unusual  sexual  irritation.  In  two  casea 
reported  by  Begbie  and  Graefe,  the  first  symptoms  appeared  after  a  violent  blow  upon 
the  head.  Among  the  predisposing  causes  we  may  mention  ansemia  (severe  diseases, 
confinement,  hremorrhages),  extreme  nervousness,  and  hysteria.  The  much  greater 
liability  of  the  female  sex  to  this  affection  under  the  influence  of  these  causes  is 
readily  under&tood.  Twenty-four  among  twenty- seven  of  Romberg's  and  Henoch's 
cafes  were  females,  and  twenty  among  twenty-five  of  Taylor's  observations.  Among 
nine  cases,  Prael  only  found  one  in  a  male  ;  nccording  to  Graefe,  the  proportion  is 
about  one  to  seven.  The  much  larger  number  of  cases  occur  from  the  twentieth  to 
the  fortieth  years  of  lif§.  Stokes  and  Trousseau  have,  in  exceptional  instances,  seen 
the  disease  in  childhood  and  in  women  past  the  age  of  sixty. 

The  most  diverse  opinions  have  been  entertained  concerning  the  nature 
of  this  peculiar  disease.  Basedow,  and  more  recently  Hiffelsheim  and 
Beau,  considered  the  primary  phenomenon  to  be  a  modification  of  the 
blood  analog-ous  to  chlorosis.  But  experience  disproves  this  view,  as  there 
is  no  manifestation  of  this  disease  in  tlie  vast  majority  of  chlorotic  patients, 
and  exophthalmic  goitre  also  develops  as  an  acute  affection  in  patients 
who  are  otherwise  healthy,  in  men  and  children,  and  from  various  causes 
(traumatic,  psychical,  and  sexual  influences).     Nor  can  we  entertain  the 


2(30  CLINICAL    TREATISE    ON 

theory  proposed  by  Piorry,  Bouillaud,  etc.,  who  attributed  the  pathogno- 
monic symptoms  of  the  disease  to  the  compression  exercised  by  the  hyper- 
trophied  thyroid  gland  upon  the  vessels  and  nerves  of  the  neck,  or  upon 
the  cervical  sympathetic  (Koeben),  as  the  thyroid  enlargement  does  not 
appear  primarily,  and  even  very  large  goitres  or  tumors  compressing  the 
sympathetic  do  not  give  rise  to  similar  morbid  phenomena. 

Stokes'  hypothesis  which  attributes  the  goitre  and  exophthalmia  to 
hypertrophy  of  the  heart,  is  also  unsatisfactory,  for  physical  exploration 
of  the  heart  frequently  reveals  nothing  abnormal  in  Basedow's  disease,  and, 
on  the  other  hand,  very  marked  organic  affections  of  the  heart  are  unac- 
companied by  any  of  these  symptoms. 

The  theory  which  is  most  in  unison  with  physiology  and  with  the 
clinical  data,  is  that  which  attributes  Basedow's  disease  to  an  affection  of 
the  sympathetic  system.  This  view  numbers  among  its  adherents  Aran, 
Trousseau,  Charcot,  Friedreich,  Geigel,  Graefe,  etc.  We  know  from  the 
experiments  of  Biffi  and  Claude  Bernard  that  section  of  the  cervical  sym- 
pathetic causes  dilatation  of  the  vessels  of  the  head  and  neck,  and  ah  eleva- 
tion of  temperature  in  the  corresponding  ear.  The  cornea  then  becomes 
flattened,  the  pupil  contracts  and  the  eyeball  sinks  into  the  orbit;  gal- 
vanization of  the  central  end  of  the  sympathetic  causes  enlargement  of 
the  palpebral  fissure,  the  restoration  of  the  corneal  convexity  and  the  pro- 
trusion of  the  eyeball  from  the  orbit.  In  accordance  with  these  experimen- 
tal data,  Geigel  (AYuerz,  Med.  Zschr.,  Bd.  VII.,  18G6)  believes  that  exoph- 
thalmic goitre  is  due  to  paralysis  of  the  cephalic  and  cervical  vascular 
nerves  contained  in  the  cervical  sympathetic,  and  to  the  simultaneous 
irritation  of  its  oculo-pupillary  fibres. 

Many  clinical  signs  appear  to  confirm  the  theory  of  paralysis  of  the 
sympathetic  in  Basedow's  disease.  Paralysis  of  the  sympathetic  vascular 
fibres  of  the  neck  and  head  produces  primarily  a  congestion  of  the  vessels, 
the  persistence  of  which  causes  the  accumulation  of  adipose  tissue  in  the 
orbit,  and  of  colloid  or  connective-tissue  elements  in  the  thyroid  gland; 
the  enfeeblement  of  nervous  action  in  the  cardiac  vaso-motor  fibres  of  the 
sympathetic  causes  the  increase  in  the  intensity  of  the  cardiac  pulsations. 

This  interpretation  is  also  supported  by  other  facts,  such  as  the  rise  of 
temperature  observed  in  many  patients;  the  ulcerations  of  the  cornea, 
which  were  regarded  by  Graefe  as  neuroparalytic  in  character;  the  unilat- 
eral or  bilateral  redness  and  heat  of  the  face  observed  by  Stellwag  and 
Geigel;  the  circumscribed  vascular  dilatations  of  the  skin  and  the  partial 
oedema  of  the  mucous  membranes;  Graefe's  observation,  in  which  the  dis- 
ease developed  within  several  days  after  intense  sexual  excitement,  that 
had  been  followed,  for  half  an  hour,  by  very  marked  vaso-motor  disturb- 
ances, etc. 

In  order  to  explain,  according  to  the  preceding  theory,  the  contradic- 
tory manifestations  of  exophthalmic  goitre,  we  are  farced  to  admit  a  sim- 
ultaneous irritation  and  paralysis  of  the  sympathetic  nerve,  whereas  we 
can  arrive  at  a  much  more  natural  and  simple  view  of  the  vaso-motor  dis- 
orders by  interpreting  the  symptoms  in  the  light  of  the  recent  experi- 
rhents  of  Goltz  (loc.  cit.).  If  we  admit  that  the  vascular  dilatation 
is  not  due  to  paralysis,  but  is  an  active  process,  caused  by  exaggerated 
function  of  the  vaso-dilator  nerves,  we  can  understand  why  the  vascu- 
lar dilatation  and  prolonged  hyper.'emia  in  the  thyroid  gland  and  in  the 
orbits  will  give  rise  to  connective-tissue  proliferation,  to  the  formation 
of  goitre,  and  the  protrusion  of  the  eyeball.  The  increased  blood-supply 
will  also  explain  the  irritation  of  the  cardiac  ganglia,  the  elevation  of 


DISEASES    OF   THE    NERVOUS    SYSTEM.  261 

temperature  which  has  been  observed  on  several  occasions,  and  the  phe- 
nomena of  psychical  excitement.  We  have  to  deal,  therefore,  in  Base- 
dow's disease,  with  a  neurosis  due  to  irritation  of  the  vaso-motor  apparatus. 
The  opposing  actions  of  the  nerves  which  pass  through  the  sympathetic 
system  must  be  attributed  to  irritation  of  their  respective  medullary 
centres. 

Basedow's  disease  almost  always  pursues  a  chronic  course,  lasting 
months  or  even  years.  Recovery  is  possible  in  recent  cases  and  in  young 
subjects  (as  is  shown  by  the  observations  of  Prael  and  others).  A  certain 
amount  of  improvement  is  obtained  in  most  cases,  but  relapses  are  not 
infrequent. 

Treatment. — Milk,  whey,  or  grape  cures  in  the  country  (Graefe),  small 
doses  of  iron,  or  iodide  of  iron;  in  palpitation,  applications  of  ice  to  the 
praecordial  region  (Aran);  Trousseau  obtained  good  results  in  some  cases 
by  mild  hydrotherapeutic  treatment.  By  means  of  galvanization,  Dusch, 
Guttmann,  Wietfeld,  and  Chvostek  have  obtained  marked  improvement, 
with  diminution  in  the  frequency  of  the  pulse,  and  in  the  goitre  and  other 
symptoms.  The  ascending  stabile  galvanic  current,  from  one  to  ten  ele- 
ments, is  passed  through  the  cervical  sympathetic  (the  anode  in  the  mas- 
toid fossa  and  the  cathode  upon  the  upper  cervical  ganglion)  for  eight  to 
ten  minutes  at  a  time.  The  current  is  also  directed  transversely  across 
the  thyroid  tumor,  or  an  ascending  current  may  be  applied  to  the  cervical 
and  upper  dorsal  vertebree. 


4.    TRAUMATIC    AND    RHEUMATIC    NERVOUS   DISORDERS    OF    THE    SYMPA- 
THETIC   SYSTEM. 

Traumatic  lesions  of  the  sympathetic  are  characterized  by  symptoms  of 
irritation  and  depression  of  the  vaso-motor  nerves  when  the  sympathetic 
system  is  compressed  by  tumors  or  has  been  injured  in  any  manner.  We  may 
regard  these  phenomena,  as  Goltz  does,  as  the  results  of  a  functional  irri- 
tation of  the  vaso-constrictor  or  vaso-dilator  nerves,  similar  to  the  effects 
produced  by  experimental  irritation  or  section  of  the  cervical  sympathetic. 

In  tumors  of  the  lateral  region  of  the  neck  or  superior  orifice  of  the 
thoracic  cavity,  we  frequently  find  the  so-called  symptoms  of  depression 
predominate.  Thus  contraction  of  the  pupils  has  been  observed  in  neo- 
plasms or  lymphatic  enlargements  in  the  neck  (Heineke,  Ogle,Willebrand), 
and  in  aneurisms  of  the  aorta  and  innominate  artery  (Gairdner,  Coates). 
In  one  of  the  latter  cases  a  cold  sweat  appeared  upon  the  face  on  the 
affected  side,  alternating  with  flashes  of  heat. 

In  Verneuil's  patient,  upon  whom  ligature  of  the  carotid  was  per- 
formed for  a  tumor  of  the  parotid  gland,  persistent  contraction  of  the 
pupil  developed  shortly  afterwards,  with  rise  of  temperature  and  vascular 
dilatation  upon  the  temple  and  gums,  and  abundant  perspiration  upon  the 
side  of  the  face  corresponding  to  the  operation.  All  these  symptoms  can 
be  produced  experimentally  upon  animals  by  dividing  the  cervical  sym- 
pathetic. 

Tumors  of  the  cervical  ganglia  and  aneurisms  of  the  aorta,  like 
electrical  irritation  of  the  cervical  sympathetic,  often  produce  dilatation 
of  the  pupils.  Upon  page  217,  Vol.  I.,  I  have  reported  certain  observa- 
tions, some  personal,  others  taken  from  various  authors,  of  ^  caries,  tuber- 
culosis, and  cancer  of  the  upper  cervical  vertebrae,  with  unilateral  dilata- 
tion of  the  pupil. 


262  CLIN^ICAL    TREATISE    ON 

In  Kidd's  patient  the  right  pupil  was  sometimes  dilated,  sometimes 
contracted,  during  the  development  of  a  suppurating  phlegmon  of  the 
neck,  and  did  not  return  to  its  normal  condition  until  the  abscess  was 
opened. 

In  a  patient  who  had  suffered  from  a  cystic  goitre,  with  mydriasis  and 
slight  exophthalmia,  Demme  found,  upon  autopsy,  well-marked  redness 
of  the  left  cervical  sympathetic  with  serous  infiltration  of  the  adjacent 
tissues.  In  Eulenburg's  case  a  vascular  goitre  of  the  right  lobe  was  ac- 
companied by  mydriasis,  paresis  of  accommodation,  and  a  reduction  of 
temperature  in  the  right  ear.  Basedow's  patient  presented  no  pupillary 
symptoms,  the  exophthalmia  was  double,  and  the  temperature  was  in- 
creased in  both  auditory  canals.  Gerhardt  and  Rossbach  have  observed 
mechanical  irritation  of  the  pneumogastric  (with  slow  pulse)  and  sym- 
pathetic nerves  (with  pupillary  dilatation)  by  supraclavicular  and  medias- 
tinal tumors. 

Examples  of  isolated  traumatic  lesions  of  the  cervical  sympathetic 
are  extremely  rare,  and  hitherto  only  a  very  small  number  have  been  col- 
lected. During  the  American  Rebellion,  Mitchell,  Morehouse,  and  Keen 
(loc.  cit.)  observed  a  soldier  who  had  received  a  bullet-wound  upon  the 
right  side,  behind  the  lower  jaw,  and  at  the  anterior  border  of  the  sterno- 
mastoid  muscle.  The  ball,  after  having  partially  traversed  the  neck, 
made  its  exit  on  the  left  side,  below  and  about  an  inch  from  the  angle  of 
the  lower  jaw;  the  wound  had  healed  after  the  lapse  of  six  weeks  The 
examination  of  the  patient,  made  during  the  tenth  week,  showed  that  the 
right  pupil  (especially  when  the  eye  was  shaded)  was  extremely  small; 
myopia,  slight  ptosis,  redness  of  the  conjunctiva,  and  frontal  pains  were 
also  present  upon  this  side.  On  several  occasions  an  unusual  redness  of 
the  left  half  of  the  face  was  observed  after  exertion.  During  repose 
the  temperature  was  normal  in  the  mouth  and  both  ears.  This  group  of 
symptoms  agrees  entirely  with  the  effects  of  experimental  section  of  the 
sympathetic  in  animals  and  with  the  pathological  observations  reported 
above.  Kaempf  reported  the  case  of  a  soldier  (Ges.  d.  Wien.  Aerzte, 
Mar.  8,  1872)  who  had  received  an  injury  of  the  right  sympathetic  from 
a  wound  in  the  cervical  region,  and  who  presented  right  paralytic  myosis, 
repeated  galvanization  of  which  proved  ineffectual. 

Wounds  of  the  cervical  region  of  the  cord  and  of  the  brachial  plexus 
also  give  rise  to  disturbances  in  the  distribution  of  the  cervical  sympa- 
thetic. The  oculo-pupillary  disorders  produced  in  these  cases,  and  their 
anatomical  relations,  have  been  discussed  on  page  211,  Vol.  I.  I  have 
also  reported  an  example  of  lesion  of  the  cervical  cord  with  persistent 
slowness  of  the  pulse  and  very  marked  dilatation  of  the  left  pupil. 

Rendu  has  since  published  some  observations  upon  fracture  of  the 
cervical  vertebrae,  in  which  unilateral  mydriasis  w^as  accompanied  by 
other  s3'^mptoms  of  irritation.  Myosis  was  observed,  however,  in  luxa- 
tions of  the  vertebrae  with  symptoms  of  paralysis  and  in  my  two  cases  of 
caries  of  the  odontoid  process,  reported  on  page  216,  Vol.  I.  Considerable 
contraction  of  the  pupil  is  also  observed  in  progressive  muscular  atrophy 
and  in  certain  forms  of  ataxia,  upon  the  side  which  is  most  affected.  In 
these  cases  periodical  attacks  of  sciatica  sometimes  occur  (usually  com- 
bined with  cutaneous  hyperaesthesia),  during  which  spasmodic  mydriasis 
appears  at  times  upon  the  same  side  as  the  neuralgia.  I  have  also  ob- 
served spasmodic  dilatation  of  the  pupils  in  attacks  of  chorea  (vide 
page  119). 

In  traumatic  lesions  oFthe  brachial  plexus,  Hutchinson  has  observed 


DISEASES    OF    THE    ISTERVOUS    SYSTEM,  263 

unilateral  myosis,  narrowing  of  the  palpebral  fissure,  and  elevation  of 
temperature  upon  the  corresponding  side  of  the  face.  Seeligmueller 
(Ber.  Klin.  Wschr.,  1870  and  1872)  has  noted,  in  addition,  emaciation 
and  atrophy  of  the  cheek  upon  the  side  of  the  wound. 

Among  the  nervous  disturbances,  dependent  on  the  cervical  sympa- 
thetic, we  must  also  mention  unilateral  hypersecretion  of  sweat  (unilat- 
eral hyperhidrosis  or  ephidrosis).  In  the  cases  of  unilateral  compression 
of  the  sympathetic,  referred  to  above,  we  have  already  alluded  to  the 
exaggerated  production  of  sweat.  Nitzelnadel,  Chvostek,  etc.,  have 
published  some  cases  of  unilateral  ephidrosis  due  to  Basedow's  disease  or 
diabetes.  The  pupil  was  contracted,  the  skin  red,  and  the  temperature 
elevated  upon  the  side  of  the  face  which  was  the  seat  of  the  hypersecre- 
tion. As  a  result  of  suppurative  parotiditis,  Botkin  has  observed  an 
elevation  of  temperature  upon  the  same  side  with  increase  in  the  vigor 
of  the  pulsations  of  the  temporal  and  facial  arteries.  In  Chvostek's  pa- 
tient, galvanization  of  the  cervical  sympathetic  caused  profuse  sweating 
upon  the  corresponding  half  of  the  face,  while  the  opposite  result  was 
obtained  in  Nitzelnadel's  case.  In  Fraenkel's  patient  (Inaug.  Diss., 
Breslau,  1874),  who  was  suffering  from  hypertrophy  of  the  heart  and 
thyroid  gland,  with  attacks  of  dyspnoea  and  hyperhidrosis  of  the  left 
half  of  the  face,  Ebstein  found  upon  autopsy  that  the  left  cervical  sym- 
pathetic was  covered  with  rounded  nodules,  as  large  as  grains  of  sand, 
and  of  a  blackish-brown  color.  Under  the  microscope  they  were  found 
to  consist  of  varicose  dilatations  of  the  vessels,  with  formation  of  fusiform- 
cells  in  the  vascular  walls  ;  the  ganglion-cells  were  markedly  pigmented 
and  filled  with  dark  cells. 

Seguin's  patient  (Amer.  Journ.  of  Med.  Sciences,  Oct.,  1872)  pre- 
sented a  suppression  of  perspiration  upon  the  right  side  of  the  face  and 
neck,  even  when  the  left  side  sweated  profusely. 

At  the  autopsy  the  right  cervical  sympathetic  was  found  adherent  to 
the  sheath  of  the  vessels  and  of  the  pneumogastric,  with  injection  of  the 
superior  ganglion  and  adjacent  parts. 

We  are  already  acquainted  {vide  page  163)  with  the  phenomena  of 
vascular  spasm  and  dilatation  which  are  produced  experimentally  by  the 
action  of  cold  upon  the  cutaneous  vascular  nerves.  Nothnagel  has  pub- 
lished (Arch.  f.  klin.  Med.,  Bd.  II.,  1867)  some  observations  relative  to 
the  influence  of  cold  upon  the  development  of  vaso-motor  nervous  dis- 
orders. In  all  these  cases  the  affection  appeared  in  women,  especially 
upon  the  forearms  and  hands  after  washing  in  cold  water.  The  symp- 
toms consisted  of  numbness  and  stiffness  of  the  limbs,  neuralgic  pains, 
manifest  diminution  of  sensibility,  difficulty  in  performing  delicate  move- 
ments, pallor  of  the  fingers,  and  a  reduction  of  temperature.  The  local 
anaemia  and  all  the  other  disorders  of  innervation  are  due  to  the  arterial 
spasm  caused  by  cold.  In  vasculo-nervous  affections.  Chapman  has 
acted  upon  the  vascular  nerves  by  making  warm  or  cold  applications 
along  the  vertebral  column. 

In  a  Case  reported  by  Eulenburg  and  Landois  (Wien.  Med.  Wschr., 
56,  1868),  the  vascular  spasm  occurred  in  paroxysms,  especially  in  the 
distribution  of  the  right  median  nerve,  and  was  accompanied  by  motor 
disturbances  (tremor  with  flexion  of  the  fingers  and  opposition  of  the 
thumb).  While  galvanic  treatment  was  being  carried  out,  an  eruption 
of  urticaria  developed,  as  an  intercurrent  phenomenon,  upon  the  palm  of 
the  hand  and  the  palmar  surface  of  the  forearm.  In  tha  treatment  of 
these  rheumatic  vascular  ::euroscs  we  must  endeavor  to  procure  relaxa- 


264  CLINICAL    TREATISE    ON 

tion  of  the  spasm  of  the  vessels;  this  may  be  done  by  energetic  friction, 
volatile  liniments  and  especially  the  continuous  current.  A  stabile  cur- 
rent is  passed  from  the  cervical  vertebrae  to  the  brachial  plexus  for  three 
to  five  minutes  (Nothnagel). 

We  have  previously  remarked  that,  in  fever,  the  stage  of  chill  is  ac- 
companied by  vascular  spasm,  with  secondary  pallor  of  the  superficial 
parts  of  the  body.  In  the  hot  stage  there  is  dilatation  of  the  vessels, 
with  redness  of  the  skin  and  active  perspiration.  The  point  of  departure 
of  these  phenomena  must  be  in  the  spinal  centres  of  vascular  innervation, 
especially  in  those  of  the  medulla  oblongata.  According  to  Claude  Ber- 
nard, fever  results  from  paresis  of  the  sympathetic  system.  He  bases 
this  opinion  upon  the  fact  that  irritation  of  the  central  end  of  a  sensory 
nerve,  in  an  animal  suffering  from  fever,  will  cause  an  abolition  of  the 
rise  of  temperature. 


5.    VASO-MOTOE  ANGINA  PECTORIS. 

We  have  previously  remarked  that  the  imperfection  of  our  actual 
knowledge  concerning  cardiac  innervation,  and  the  absence  of  sufficient 
anatomo-pathological  data,  prevent  us  from  obtaining  a  clear  clinical  in- 
terpretation of  the  disorders  of  the  nervous  system  of  the  heart.  We  re- 
fer to  page  219,  for  the  symptoms  of  angina  pectoris,  but,  in  order  to  ren- 
der the  subject  complete,  shall  here  mention  a  certain  number  of  facts 
which  tend  to  demonstrate  the  participation  (at  least  partial)  of  the  sym- 
pathetic system  in  the  symptomatology  of  this  affection.  According  to 
Bezold's  experiments  (Travaux  du  Laboratcire  de  Wuerzbourg,  1867),  the 
heart  receives  sympathetic  fibres,  some  of  which  are  contained  in  the  cer- 
vical sympathetic,  while  others  originate  in  the  brain,  and  pass  to  the 
inferior  cervical  ganglion  and  cardiac  plexuses  through  the  cervical  and 
dorsal  portions  of  the  cord.  These  fibres  transmit  to  the  heart  the  central 
stimuli  which  cause  its  contractions  to  become  slower.  An  observation, 
made  by  Lancereaux  (Gaz.  JNIed.,  1864),  shows  that  changes  in  the  cardiac 
plexus  may  give  rise  to  symptoms  of  angina  pectoris.  The  patient  died 
in  an  attack  of  stenocardia  (to  which  he  had  been  subject),  and  the  au- 
topsy showed  the  existence  of  lesions  in  the  aorta,  considerable  narrow- 
ing of  the  coronary  arteries,  injection  of  the  vascular  walls  and  of  the 
cardiac  plexus,  and  an  accumulation  of  nuclei  in  the  nerve-fibres  and  gan- 
glia between  the  more  or  less  compressed  nerve-tubes. 

As  the  vascular  nerves  of  the  heart  are  contained  in  the  sympathetic, 
it  is  conceivable,  from  the  experiments  of  Ludwig,  Thiry,  and  the  Cyon 
brothers,  that  the  pressure  in  the  aortic  system  and  the  cardiac  action 
should  be  increased  or  diminished,  according  to  irritation  or  relaxation 
of  the  vaso-motor  apparatus.  Finally,  the  observations  of  Landois 
(Corresp.-Blatt.  f.  Psych.,  1866)  and  Nothnagel  (Arch.  f.  klin.  Med.,  Bd. 
III.,  1867)  also  tend  to  demonstrate  the  sympathetic  origin  of  a  large 
number  of  cases  of  stenocardia.  The  latter  author  has  published,  under 
the  term  vaso-motor  angina  pectoris,  some  cases  in  which  the  symptoms 
of  stenocardia  had  followed  spasm  of  the  arteries,  usually  from  cold. 

The  attack  is  manifested  by  the  following  subjective  symptoms  : 
heaviness,  formication,  numbness,  and  a  sensation  of  cold  in  the  limbs, 
followed  by  prtecordial  anxiety  and  palpitation  of  the  heart,  terminating 
even  in  syncope.  Dull  pain  in  the  region  of  the  heart,  dyspnoea,  and 
vertigo  are  also  observed-at  times.     The  list  of  objective  symptoms  com- 


DISEASES    OF   THE    NERVOUS    SYSTEM.  265 

prises  extreme  pallor  of  the  face,  ears,  and  limbs,  cyanosis  of  the  finger 
and  toe  nails,  marked  diminution  of  sensibility,  fall  of  temperature,  and  the 
presence  of  a  cold,  viscid  sweat  upon  the  skin.  The  cardiac  pulsations  are 
often  more  rapid,  at  other  times  regular,  and  rarely  diminished,  the  heart- 
sounds  are  normal,  the  radial  pulse  tense,  but  seldom  slow;  in  one  case 
a  large« quantity  of  clear  urine  (nervous  urine)  was  discharged.  Accord- 
ing to  Nothnagel  and  Eichwald,  palpitation  of  the  heart  is  caused  by  the 
increased  resistance  which  the  heart  meets  with  on  all  sides  from  the  con- 
tracted vessels;  the  dread  and  prrocordial  pains  are  caused  by  the  over- 
exertion to  which  the  heart  is  subjected.  Paroxysms  of  this  nature  may 
occur,  with  variable  intensity  and  duration,  either  daily  or  at  the  end  of 
certain  intervals,  during  which  the  health  remains  satisfactory,  or  the  pa- 
tient suffers  from  persistent  headache  (Cordes). 

The  affection  only  appears  in  adults,  in  men  and  women  of  all  classes 
and  pursuits.  The  action  of  cold  (washing  in  cold  water,  damp  feet, 
moist  dwellings)  is  the  chief  etiological  factor.  The  disease  is  most  fre- 
quent in  winter  and  in  rigorous  climates;  it  usually  disappears  in  the 
mild  season,  and  returns  in  the  following  winter.  The  prognosis  is  almost 
always  favorable.  Old  cases  are  very  intractable  to  treatment,  but  even 
in  these  instances  the  paroxysms  terminate  after  a  certain  length  of  time. 
The  treatment  aims  to  diminish  the  vascular  spasm  and  to  favor  the  flow 
of  blood  to  the  integument.  Warm  full-baths  and  foot-baths,  friction  of 
the  limbs,  stimulating  liniments,  etc.,  are  the  remedies  employed.  We- 
should  avoid  the  action  of  cold  upon  the  limbs,  and  endeavor  to  counter- 
act the  aniBmia.  Frictions  with  moderately  cold  water  serve  to  prevent 
a  relapse. 

G.    NEUROSES    OF    THE    ABDOMINAL    SYMPATHETIC. 

This  category  includes  certain  peculiar  nervous  disorders  which  are> 
observed  in  the  abdominal  viscera,  within  the  distribution  of  the  abdomi- 
nal sympathetic  and  of  the  cerebro-spinal  nerves  with  which  it  communi- 
cates. 

Enteralgia  (colic),  caused  by  rheumatic  influences,  psychical  excite- 
ment, or  hysteria,  and  which  is  also  called  hyperJBsthesia  or  neuralgia  of 
the  mesenteric  plexus,  had  been  recognized  by  the  older  writers  as  an 
affection  of  the  sympathetic  system.  Tanquerel  des  Planches,  the  dis- 
tinguished writer  on  saturnine  affections,  regarded  lead  colic  as  dependent 
on  the  sympathetic  system  (Traite  des  Maladies  de  Plomb.,  1839).  Never- 
theless, among  forty-nine  autopsies  on  patients  who  had  suffered  from 
this  disease,  only  one  was  found  in  which  the  abdominal  ganglia  of  the 
sympathetic  were  changed  (increased  to  two  or  three  times  their  nor- 
mal volume,  and  colored  yellowish  gray  as  compared  with  the  correspond- 
ing ganglia  in  two  other  subjects).  Segond  also  found  the  ganglia  and 
some  fibres  of  the  sympathetic  hypertrophied  and  indurated  (Essai  sur  la 
nevralgie  du  grand  sympathique,  colique  de  Poitou,  1837).  Within 
recent  times,  Kussmaul  and  Maier  have  published  an  example  of  sclerosis 
of  the  coeliac  and  superior  cervical  ganglia,  in  a  case  of  chronic  lead- 
poisoning.     We  have  referred  to  this  case  in  detail  on  page  141. 

We  are  taught  by  physiologists  that  the  motor  nerves,  which  the  sym- 
pathetic system  distributes  to  the  muscular  fibres  of  the  viscera  and  ves- 
sels, are  chiefly  contained  in  the  anterior  roots,  the  posterior  roots  serv- 
ing for  the  transmission  of  sensory  stimulation  or  centripetal  impressions 
received  by  the  same  sympathetic  fibres.     The  abdominal  vascular  nerves 


266  CLINICAL    TREATISE    ON 

terminate  centrally  in  the  brain.  Lesions  of  the  corona  radiata,  optic 
thalamus,  and  even  of  the  corpus  callosum  give  rise,  according  to  Valen- 
tin and  others,  to  hyperasmia  of  the  abdominal  viscera,  especially  of 
the  small  intestines,  and  to  softening  and  ulceration  of  the  mucous  mem- 
brane. We  can  frequently  notice,  in  recently  killed  animals,  that  irrita- 
tion of  the  optic  thalamus  or  cerebral  peduncle  does  not  affect  the  striated 
muscles,  but  causes  contraction  of  the  muscular  fibres  of  the  intestines 
and  other  abdominal  viscera. 

It  follows  from  these  considerations  (which  are  also  applicable,  in  large 
part,  to  man)  that  central  irritation  (excitement)  may  give  rise  to  enter- 
algia,  especially  in  very  impressionable  patients.  On  the  other  hand,  the 
abnormal  irritation  of  the  intestinal  miiscular  fibres  or  intra-muscular 
nerve-fibres  (perhaps  from  the  lead  which  has  been  detected  by  Devergie, 
Meurer,  and  Orfila  in  the  intestinal  walls  of  patients  suffering  from  lead- 
poisoning)  may  reach  the  nerve-centres  through  the  paths  of  transmission 
mentioned  above,  and  may  thus  give  rise  to  reflex,  movements  in  the  mus- 
cular apparatus  of  the  intestines.  Colic  cannot  therefore  be  regarded 
as  a  mere  hyperassthesia  of  the  mesenteric  plexus. 

The  remaining  symptoms  of  lead  colic,  such  as  pallor  and  coolness  of 
the  face  and  limbs,  the  slow,  small,  and  hard  pulse,  and  irregular  respira- 
tion, must  be  attributed  (as  Eulenburg  and  Landois  have  emphasized,  loc. 
cit.)  to  irritation  of  the  medullary  centre  of  the  pneumogastric  and  to  re- 
flex arrest  of  the  cardiac  and  respiratory  movements,  as  in  Goltz's  experi- 
ments upon  percussion  of  the  intestines.  The  fibres  which  act  in  a  reflex 
manner  upon  the  pneumogastric  are  contained,  according  to  Bernstein 
(Centralbl.,  52, 1 864),  in  the  sympathetic  system  and  reach  the  cord  through 
the  anastomotic  branches.  Section  of  the  sympathetic  above  this  point 
will  interfere  with  Goltz's  percussion  experiment.  In  frogs,  according  to 
Bernstein,  the  nerve-fibre  which  accompanies  the  mesenteric  artery  trans- 
mits the  reflex  fibres  of  the  abdominal  viscera  to  the  sympathetic  system, 
and  stimulation  of  this  nerve  produces  arrest  of  the  heart's  action.  Ac- 
cording to  Asp's  recent  experiments,  stimulation  of  the  central  end  of 
the  splanchnic  nerve  causes  retardation  of  the  pulse  and  an  elevation  of 
the  arterial  pressure.  We  cannot  state  with  certainty,  however,  that  the 
syncopal  attacks  observed  by  Romberg  in  lead  colic  are  due  to  a  reflex 
arrest  of  the  heart's  action.  The  severe  and  obstinate  constipation,  which 
almost  always  accompanies  lead  colic,  may  be  attributed  to  the  prolonged 
irritation  of  the  splanchnic  nerve,  which  acts  as  the  inhil)itory  nerve  of 
intestinal  movements  (Pflueger).  The  recent  experiments  of  Basch  and 
S.  Mayer  (Wien.  Akad.  Sitz. -Berichte,  1870  and  1873)  and  of  Hougkest 
van  Braam  (Pflueg.  Arch.,  1873)  have  shown  that  the  inhibitory  action 
■of  the  pneumogastric  results  from  the  vaso-motor  functions  of  this  nervo. 
The  vaso-motor  fibres  of  the  pneumogastric  originate  in  the  medulla 
oblongata. 

Autenrieth  and  Romberg  have  described  a  hyperesthesia  of  the  solar 
plexus  (coeliac  neuralgia)  with  pains  in  the  epigastrium  (as  in  neuralgic 
gastrodynia)  which  radiate  into  the  thorax  and  towards  the  back.  In  the 
absence  of  material  lesions  and  of  a  sufficient  physiological  foundation,  we 
are  not  entirely  justified  in  attributing  these  phenomena  to  an  affection  of 
the  sympathetic. 

Gastralgias,  like  the  "  crises  gastriques,"  which  are  sometimes  ob- 
served in  the  irritation-stage  of  ataxia,  are  explained  more  readily  by  the 
sensory  fibres  recently  discovered  in  the  pneumogastric. 

Extirpation  of  the  solar  plexus  merely  produces  trophic  disorders  in 


DISEASES    OF    THE    NERVOUS    SYSTEM.  267 

the  stomach  and  upper  part  of  the  small  intestine.  Hyperaesthesia  of  the 
hypogastric  plexus  (painful  sensations  in  the  hypogastric  and  sacral  re- 
gions, radiating  towards  the  thighs  and  hfemorrhoidal  nerves)  has  also  been 
recognized,  but  the  actual  condition  of  our  physiological  knowledge  will 
not  sanction  the  expression  of  an  opinion  as  to  its  character.  Hyperaes- 
thesia of  the  spermatic  plexus  constitutes  the  neuralgia  of  the  testis, 
which  we  discussed  in  connection  with  the  neuralgias  of  the  cerebro-spinal 
branches  of  the  lumbar  plexus. 

This  category  also  includes  the  neuralgia  of  the  urethral  canal  (which 
is  almost  always  accompanied  by  local  hypersesthesia  and  other  symptoms 
of  irritation  of  the  cord),  the  acute  pains  at  the  neck  of  the  bladder  (with 
frequent  desire  to  urinate)  and  in  the  rectum  (with  tenesmus,  constipa- 
tion, sensation  of  great  heat),  which  Duchenne  observed  in  a  physician 
who  was  suffering  from  beginning  ataxia.  The  pains  recurred  at  inter- 
vals of  two  or  three  months,  and  continued  for  twenty-four  hours;  they 
disappeared  after  the  use  of  purgatives  or  the  appearance  of  diarrhoea. 
At  a  later  period  lancinating  pains  occurred  with  cutaneous  hyperjesthe- 
sia,  unilateral  amblyopia,  and  mydriasis  without  diplopia;  ejaculation  dur- 
ing coitus  occurred  precipitately.  Nevertheless  no  marked  disturbance 
was  noticeable  in  the  gait. 

The  neuroses  of  the  urethra,  neck  of  the  bladder,  and  of  the  rectum, 
which  sometimes  develop  in  the  irritation-stage  of  ataxia,  must  be  re- 
garded as  symptoms  of  irritation  of  the  lumbar  cord,  and  especially  of  the 
genito-spinal  and  ano-spinal  centres.  The  hypothesis  of  a  functional  dis- 
order of  the  abdominal  sympathetic  is  here  entirely  superfluous.  We 
refer,  for  further  details,  to  the  remarks  made  on  pages  247,-249,  Vol.  I. 

Some  writers  have  also  described  anaesthesije  of  the  sympathetic  sys- 
tem. Although,  according  to  Hasse's  recent  experiments,  certain  poisons 
(such  as  opium  and  curare)  greatly  increase  the  reflex  excitability  of  the 
intestines,  it  is  none  the  less  true,  in  a  general  sense,  that  all  portions  of 
the  sympathetic  normally  present  but  a  very  slight  degree  of  sensibility. 
Neither  anatomical  nor  physiological  data  enable  us  to  entertain  a  decided 
opinion  concerning  the  ana?sthesite  under  consideration.  The  suppres- 
sion of  movements  (those  of  the  intestines,  for  example)  may  be  due  to 
the  abolition  of  the  direct  excitability  of  the  peripheral  ganglia  as  well  as 
to  disturbances  of  conduction  in  the  reflex  paths. 

Our  information  with  regard  to  atrophy  of  the  abdominal  portion  of 
the  sympathetic  is  still  extremely  meagre.  In  a  case  of  diabetes  melli- 
tus, reported  by  Munk  (Naturforscherversammlung,  Innsbruck,  18G9), 
Klebs  found  atrophy  of  the  solar  ganglion,  the  nerve-filaments  supplying 
the  hepatic  artery  being  intact.  Experiments  have  been  made  in  dogs 
upon  the  part  played  by  the  solar  ganglion  in  the  development  of  diabetes. 
Partial  extirpation  of  the  ganglion  gave  rise  to  glycosuria,  which  either 
lasted  until  death  (one  to  two  weeks)  or  was  merely  temporary.  In  the 
latter  case  the  diabetes  returned  temporarily,  after  its  previous  disap- 
pearance, under  the  influence  of  an  exclusively  animal  diet.  Under  a 
vegetable  diet  it  returned  for  a  few  days,  and  then  disappeared  entirely. 
Upon  making  an  autopsy  in  these  cases,  Klebs  found  a  marked  degenera- 
tion of  the  elements  of  the  nervous  tissue.  Neither  section  of  the  hepatic 
nerves  nor  of  the  pneumogastrics  is  sufficient,  in  itself,  to  give  rise  to  dia- 
betes. Lubimoff  found  sclerosis  of  the  cells  of  the  coeliac  ganglion  in 
diabetes  mellitus  (Virch.  Arch.,  Bd,  LXI). 


268  CLINICAL    TREATISE    ON 


7.  Addison's  disease. 

The  peculiar  symptomatolog-y  which  is  characteristic  of  degeneration 
of  the  suprarenal  capsules  was  first  described  by  Thomas  Addison  (On  the 
Constitutional  and  Local  Effects  of  Disease  of  the  Suprarenal  Capsules, 
London,  1855).  The  clinical  signs  of  the  disease  in  question  are:  deposit 
of  a  dark,  bronze-colored  pigment  in  the  rete  Malpighii,  more  rarely  in 
the  internal  organs;  symptoms  of  irritation  on  the  part  of  the  digestive 
canal  (vomiting,  abdominal  or  lumbar  pains,  etc.);  great  muscular  weak- 
ness; anaemia  almost  always  terminating  in  death. 

The  most  frequent  anatomical  lesion  is  a  chronic  inflammation  of  the 
suprarenal  capsules,  the  exudation  into  which  is  usually  cheesy  (tuberculari- 
zation).  A  bronzed  coloration  of  the  skin  is  seen  during  life  in  very  excep- 
tional cases  of  cancer  and  echinococci  of  the  suprarenal  capsules  (Huber). 
Arerbeck  has  published  a  complete  monograph,  comprising  all  the  cases 
reported  prior  to  1867  (Die  Addison'sche  Krankheit,  Erlangen,  1869). 

Experimental  investigations  have  not  hitherto  contributed  much  to- 
wards clearing  up  the  pathology  of  the  suprarenal  capsules.  According 
to  Brown-Sequard,  animals  succumb  more  rapidly  after  extirpation  of 
these  organs  than  after  removal  of  the  kidneys  or  wounds  of  the  perito- 
neum. Nevertheless  some  of  the  larger  or  smaller  animals  thus  operated 
upon  may  survive. 

With  regard  to  the  accumulation  of  pigment  in  the  blood  after  extir- 
pation of  the  suprarenal  capsules,  Brown-Sequard  has  seen  injection  of 
this  blood  rapidly  produce  death  in  an  animal  in  whom  only  one  capsule 
had  been  removed,  while  animals  deprived  of  both  organs  could  be  kept 
alive  for  several  hours  by  injecting  the  blood  of  a  healthy  animal.  The 
accumulation  of  pigment  in  the  blood  causes  its  elimination  by  the 
capillaries  and  congestion  of  the  latter,  with  circulatory  disturbances  ter- 
minating in  death.  Nevertheless  the  experiments  of  Philippeaux,  Har- 
ley,  Berruti,  and  Perusino  have  shown  that,  after  extirpation  of  both 
suprarenal  capsules,  large  as  well  as  small  animals  may  survive  for 
months  without  presenting  pigmentary  anomalies  in  the  skin  or  internal 
organs.  According  to  Schiff,  extirpation  of  the  suprarenal  capsules,  or 
of  the  nerves  distributed  to  them,  does  not  give  rise  to  any  change  of 
color  either  in  pigmented  animals  or  in  albinos. 

As  experimentation  merely  furnishes  us  with  negative  results,  other 
facts,  such  as  the  great  abundance  of  nervous  elements  in  the  paren- 
chyma of  the  suprarenal  capsules,  and  the  relations  of  these  elements 
with  the  sympathetic  system,  assume  a  so  much  greater  importance. 
According  to  recent  investigations  by  Ecker,  Koelliker,  and  J.  Arnold, 
the  semi-lunar  ganglion  furnishes  the  suprarenal  capsules  with  numerous 
nerve-fibres,  which  are  provided  with  ganglia  and  form  a  kind  of  network 
in  the  interior  of  these  organs.  Virchow  has  also  found,  in  their  paren- 
chyma, large  nerve-cells,  furnished  with  prolongations,  and  Holm  has 
described  a  second  variety  of  cells  much  smaller  and  destitute  of  prolon- 
gations. This  abundance  of  afferent  nerves,  compared  with  the  small 
size  of  the  organs,  and  the  considerable  number  of  ganglion-cells,  which 
must  be  regarded  as  origins  of  nerves,  prov^e  that  the  suprarenal  capsules 
possess  intimate  relations  with  the  abdominal  sympathetic  plexuses.  On 
the  other  hand,  the  absence  of  all  secretory  function  and  the  structure  of 
the  capsules  will  not  justify,  us  in  regarding  them  as  glandular  organs. 

Although  the  experiments  performed  upon  the  abdominal  sympathetic 


DISEASES    OF    THE    NERVOUS    SYSTEM.  269 

plexus  by  Pincus,  Samuel,  Budge,  and  Adrian  have  not  given  rise  to  any 
of  the  changes  characteristic  of  Addison's  disease,  anatomical  investiga- 
tions have  revealed,  in  a  large  number  of  cases,  degenerations  in  the 
S3'mpathetic  system.  In  addition  to  the  changes  in  the  suprarenal  cap- 
sules (retraction  of  the  cells  and  nuclei,  with  fatty  detritus),  the  following 
lesions  have  been  found;  bright  redness  and  enlargement  of  the  coeliac 
ganglion  and  of  the  sympathetic  nerves  (Monro,  Recklinghausen),  fatty 
degeneration  of  the  solar  plexus  and  semi-lunar  ganglia  (Quekett,  Mein- 
hardt,  Bartsch,  Southey),  atrophy  of  the  abdominal  sympathetic  and  of 
the  solar  plexus  (J.  Schmidt,  Van  Audel),  hypertrophy  of  the  solar 
plexus,  semi-lunar  ganglia,  and  efferent  nerve-fibres  (Virchow,  Green- 
how,  Wolff,  Burresi),  adenoid  degeneration  of  the  semi-lunar  ganglia 
and  of  their  nerve-filaments  (Sanderson),  purulent  softening  of  a  part  of 
the  solar  plexus,  starting  from  the  suprarenal  capsules  (A.  Fraenkel). 

Among  twenty-nine  autopsies,  anatomical  lesions  were  found  in  nine 
teen;  but  in  ten  cases  the  sympathetic  nerves  remained  intact.  But 
all  parts  of  the  sympathetic  were  not  examined  in  these  cases,  and  in  the 
future  this  examination  should  be  carefully  performed.  We  refer,  for 
further  details,  to  the  investigations  of  Eulenburg  and  Guttmann  (Patho- 
logie des  Sympathicus,  Berlin,  1873). 

The  clinical  symptoms  of  Addison's  disease  are  evidence  of  a  serious 
affection  of  the  entire  nervous  system.  Apart  from  the  characteristic 
pigmentation  of  the  integument  of  the  trunk  and  of  the  accessible  mucous 
membranes  (with  the  exception  of  the  conjunctiva  and  of  the  nails),  we 
find  the  following  indications  of  a  nervous  affection  :  frequent  cephalalgia, 
vertigo,  syncopal  attacks,  neuralgic  pains  in  the  limbs,  shoulders,  sacrum, 
and  epigastrium;  later,  dyspepsia  and  vomiting,  diarrhoea,  mental  depres- 
sion, hallucinations,  and  great  muscular  weakness.  The  convulsions 
which  are  sometimes  observed  must  be  regarded  as  due  to  cerebral  anse- 
mia;  the  anaemia  of  the  nerve-centres  ends  in  cachexia,  exhaustion,  and 
somnolence,  which  terminate  in  death. 

According  to  Risel,  Addison's  disease  consists  of  a  paralysis  of  the  ab- 
dominal sympathetic  plexuses  from  a  propagation  of  the  inflammatory 
processes  developed  in  the  suprarenal  capsules;  this  gives  rise  to  general 
anaemia  on  account  of  the  stasis  of  blood  in  the  abdominal  viscera.  Ac- 
cording to  Rossbach,  the  symptomatology  depends  upon  a  functional  dis- 
turbance of  the  entire  nervous  system,  which  cannot  be  demonstrated 
anatomically,  and  which  is  presided  over  in  a  direct,  though  not  indispen- 
sable, manner  by  the  suprarenal  capsules. 

The  diagnosis  of  Addison's  disease  is  based  chiefly  on  the  discolora- 
tion of  the  skin,  varying  from  a  clear  brown  to  a  bronze  tint,  and  upon 
the  feeling  of  intense  weakness  which  is  very  often  accompanied  by  pro- 
found moral  depression.  When  the  discoloration  of  the  skin  is  less 
marked  or  the  pigment  has  not  been  deposited  on  account  of  the  rapid 
progress  of  the  disease  (Gull's  observation  with  degeneration  of  both  su- 
prarenal capsules  and  of  the  right  semi-lunar  ganglion),  the  adynamia 
and  diarrhoea  may  lead  us  to  suspect  typhoid  fever  or  acute  miliary  tu- 
berculosis. But  the  absence  of  a  rise  of  temperature,  of  enlargement  of 
the  spleen  and  of  meteorism,  enables  us  to  exclude  typhoid  fever  in  these 
cases.  The  slight  importance  of  the  fever,  and  the  trifling  increase  in  the 
number  of  the  respiratory  movements,  preclude  the  idea  of  miliary  tuber- 
culosis. When  it  is  possible  to  examine  the  patient  for  any  length  of 
time,  we  should  especially  direct  our  attention  to  the  discoloration  of  the 
skin  and  to  the  nervous  disorders  to  which  we  have  referred. 


270  CLINICAL    TREATISE    ON 

The  disease  almost  always  pursues  a  chronic  course,  and  lasts  months 
or  even  years.  The  affection  was  acute  in  two  cases  reported  by  Virchow 
(with  recent  haemorrhagic  inflammation  of  the  suprarenal  capsules),  but 
it  was  found  that  the  patients  had  died  in  the  midst  of  typhoid  symptoms. 

The  2WO(jnosis  is  usually  unfavorable.  Temporary  improvement  and 
periods  of  arrest  in  the  course  of  the  symptoms  are  to  be  looked  for 
rather  than  recovery.  In  the  majority,  if  not  in  all  the  cases,  the  disease 
terminates  in  death,  which  is  frequently  hastened  by  the  invasion  of  an 
acute  or  chronic  pulmonary  tuberculosis.  The  treatment  should  be  invig- 
orating and  sedative. 


8.    MUSCULAR    PSEUDO-HYPEBTROPHY. 

This  affection,  which  had  been  described  in  1838  by  Coste  and  Gioja, 
and  more  carefully  investigated  by  Duchenne,  has  been  called  lipomatosis 
musculorum  luxurians  (Heller),  atropia  musculorum  lipomatosis  (Seidel), 
myosclerotic  paralysis  (Duchenne).  We  are  much  better  acquainted  with 
its  clinical  history  than  with  the  anatomical  lesions.  If  we  examine  cases 
of  this  disease,  reports  of  which  have  become  very  numerous  during  the 
last  few  years  (Friedreich,  in  his  work  upon  progressive  atrophy,  has  col- 
lected all  the  known  examples  of  true  and  false  muscular  hypertrophy), 
we  will  find  that  the  male  sex,  childhood,  and  morbid  hereditary  predispo- 
sition play  an  extremely  important  part  from  an  etiological  point  of  view. 
The  proportion  in  females  is  only  seventeen  to  one  hundred:  the  cases 
are  most  numerous  from  the  fifth  to  the  tenth  years  of  life,  much  rarer 
towards  the  period  of  puberty,  and  exceptional  in  adults. 

Heredity  is  one  of  the  most  active  predisposing  causes.  In  the  same 
manner  that  the  male  sex  presents  in  progressive  muscular  atrophy  a 
congenital  diathesis,  which  appears  to  consist  of  a  diminution  in  the  re- 
sistance of  the  motor  and  trophic  nervous  system  to  exertion  and  fatigue, 
so  there  is  a  congenital  predisposition,  in  muscular  pseudo-hypertrophy, 
to  nutritive  disturbances  and  hyperplasia  of  the  muscular  tissue. 

In  a  large  number  of  instances  several  brothers  and  sisters,  or  several 
members  of  the  same  family,  fall  victims  to  the  disease.  Bad  hygienic 
conditions,  fatigue,  exposure,  and  febrile  diseases  have  sometimes  ap- 
peared to  favor  its  development. 

The  clinical  history  of  muscular  pseudo-hypertrophy  is  very  character- 
istic. It  almost  always  occurs  in  sickly  children,  who  develop  slowly  and 
begin  to  walk  very  late  and  with  great  difficulty.  In  the  beginning  the 
movements  are  only  slowed,  the  walk  becomes  slower  and  more  fatiguing, 
and  the  child  becomes  rapidly  tired,  even  from  standing.  The  legs  are 
separated  from  one  another,  and  the  gait  is  staggering  and  uncertain. 

The  sacro-lumbar  region  is  often  saddle-backed  from  paralysis  of  the 
extensors  of  the  vertebral  column  (Duchenne).  At  a  more  advanced  pe- 
riod (at  the  end  of  several  months  or  a  year)  a  considerable  increase  oc- 
curs in  the  volume  of  the  thighs,  which  is  often  accompanied  by  talipes 
equinus  and  flexion  of  the  toes  en  griffe.  Little  by  little  tlie  other  mus- 
cles are  affected  in  their  turn,  and  the  hypertrophy  extends  by  preference 
to  the  buttocks,  the  extensors  of  the  vertebral  column,  and  to  the  muscles 
of  the  shoulder  and  thorax.  As  this  hypertrophy  is  often  combined  with 
atrophy  of  the  trunk  and  upper  limbs,  the  body  of  a  sickly  infant  appears 
to  be  placed  upon  the  legs  of  a  vigorous  adult. 

At  a  still  later  period,  fibrillary  contractions  are  often  observed  in  the 


DISEASES    OF    THE    NERVOUS    SYSTEM.  271 

hypertrophied  muscles  (Wagner,  Eulenburg,  etc.).  The  skin  of  the  dis- 
eased parts  is  tracked  by  large  veins,  and  is  as  white  as  marble.  The 
temperature  is  sometimes  markedly  lowered;  sensibility  presents  no  spe- 
cial modifications. 

Electrical  exploration  gives  various  results  according  to  the  degree  of 
intensity  of  the  muscular  degenerations  and  the  functional  disorders. 
The  best-preserved  muscles  and  the  nerve-trunks  of  these  parts  react 
normally  to  the  faradic  and  galvanic  currents.  The  faradic  contractility 
is  visibly  weakened  in  those  nerves  and  muscles  which  are  moderately 
affected. 

According  to  Eulenburg  (Virch.  Archiv,  Bd.  LIIL),  the  contractions 
are  stronger  at  the  closure  of  the  anode  than  at  the  closure  of  the  cathode, 
and  the  "opening"  contractions  are  sometimes  entirely  wanting.  Barth 
(Arch.  f.  Heilk,,  Bd.  XII,,  1871)  also  found  the  farado-muscular  contrac- 
tility abolished,  and  only  slow  and  feeble  contractions  produced  by  strong 
galvanic  currents.  All  electrical  excitability  disappears  in  the  muscles  in 
which  the  paralysis  and  degeneration  have  attained  their  maximum. 
Electro-muscular  sensibility  has  been  found  to  be  either  increased  or 
diminished. 

After  longer  or  shorter  stationary  periods,  the  last  vestiges  of  vol- 
untary motion  disappear,  and  the  child  is  entirely  helpless  and  unable  to 
leave  the  bed.  In  the  prone  position  the  hypertrophied  lower  limbs  pre- 
sent slight  contractures  at  the  hip  and  knee,  the  thigh  is  rotated  out- 
wards, and  the  contraction  of  the  muscles  of  the  leg  gives  rise  to  talipes 
equinus  and  varo-equinus.  The  muscles,  which  are  at  first  increased  in 
size,  then  become  atrophied,  and  certain  groups  of  muscles,  especially  in 
the  upper  limbs,  present  very  pronounced  atrophy,  although  the  legs  are 
still  entirely  misshapen.  Other  complications  are  sometimes  observed, 
such  as  diminution  of  intelligence,  slowness  of  speech,  and  convulsions. 
The  patients  often  succumb  to  diseases  of  the  respiratory  organs. 

The  anatomical  changes  in  the  muscles  have  been  studied  either  in 
the  living  subject  (by  excision  or  harpooning)  or  only  after  death. 

The  pale,  discolored,  and  enlarged  muscles  show  atrophy  of  the  fibrillse, 
even  to  complete  disappearance,  and  an  abundant  development  of  inter- 
stitial adipose  tissue.  Many  cases  present  hyperplasia  of  the  interstitial 
connective  tissue,  with  simple  atrophy  of  the  muscular  fibres,  which 
Billroth,  Charcot,  Knoll,  etc.,  regard  as  the  primary  disease.  The  accu- 
mulation of  fat  in  the  proliferated  connective  tissue,  which  has  developed 
at  the  expense  of  the  internal  perimysium,  only  occurs  secondarily  after 
the  progressive  atrophy  and  the  final  disappearance  of  the  muscular 
tissue.  Waxy,  tubular  atrophy,  with  formation  of  fissures  in  the  primi- 
tive fibres,  has  hitherto  been  observed  only  by  Martini.  On  the  other 
hand,  granular  infiltration  of  some  muscular  fibres  (parenchymatous  exu- 
dation) and  proliferation  of  muscular  nuclei  have  been  several  times 
noted  by  Charcot,  Cohnheim,  and  Friedreich. 

Cohnheim  was  the  first  to  discover  in  the  muscles,  which  were  increased 
in  size,  hj^pertrophied  muscular  fibres  (two  or  three  times  larger  than  the 
normal  primitive  fibres)  between  the  atrophied  elements,  and  this  observa- 
tion has  been  confirmed  by  Eulenburg,  Barth,  Mueller,  and  Knoll.  Within 
recent  times,  Auerbach  (Virch.  Arch.,  LIII.  Bd.),  Berger  (Deutsch.  Arch, 
f.  klin.  Med.,  1872),  and  Hitzig  (Ber.  Klin.  Wschr.,  1872)  have  observed 
some  cases  of  true  hypertrophy  of  the  muscular  fibres,  without  prolifera- 
tion of  the  interstitial  connective  tissue,  and  the  two  first-mentioned 
authors  have  noticed  this  in  the  initial  stage  of  muscular  pseudo-hyper- 


272  CLINICAL    TEEATISE    OK 

trophy,  which  terminated,  at  a  later  period,  in  atrophy  of  the  hypertro- 
phied  fibres  and  hyperplasia  of  the  interstitial  tissue.  The  case  of  true 
muscular  hypertrophy  of  the  left  upper  limb,  described  by  Friedreich 
(loc.  cit.)  was  a  congenital  condition,  with  which  we  are  not  concerned  at 
the  present  time. 

The  examination  of  the  nervous  system,  which  has  been  made  in  a 
small  number  of  cases  of  muscular  pseudo-hypertrophy,  has  furnished 
neo-ative  results.  In  Meryon's  two  patients,  and  in  the  cases  examined  by 
Cohnheim  and  Charcot,  no  pathological  changes  were  found  in  the  sym- 
pathetic system,  in  the  columns  of  the  cord,  in  the  anterior  gray  horns, 
which  were  studied  with  especial  care,  or  in  the  roots  of  the  nerves  and 
peripheral  nerve-trunks.  On  the  other  hand,  Earth's  case  (Arch.  f.  Heilk., 
Bd.  XII.,  1871)  presented  sclerosis  of  the  antero-lateral  columns,  with 
considerable  vascular  dilatation  and  partial  atrophy  of  the  cells  in  the 
anterior  horns.  In  W.  Mueller's  case  (Beitr.  z.  path.  Anat.  u.  Phys.  d. 
menschl.  Rueckenm.,  Leipzig,  1871)  the  cord  presented  very  extensive  de- 
generation, especially  in  the  lateral  columns,  with  atrophy  of  the  cells  of 
the  anterior  horns  and  obliteration  of  the  central  canal.  But  in  Charcot's 
opinion,  Barth's  case  was  one  of  symmetrical  sclerosis  of  the  lateral 
columns  (lateral  amyotrophic  sclerosis,  vide  page  262,  Vol.  I.)  accompanied 
by  degeneration  of  the  anterior  horns,  and,  in  Mueller's  case,  the  gray  de- 
generation of  the  spinal  columns,  with  atrophy  of  the  cells  of  the  anterior 
horns,  the  chronic  meningitis,  ependymitis,  and  cellular  infiltration  of  the 
vessels  of  the  brain  and  cord,  must  be  attributed  to  the  general  parah'sis 
from  which  the  patient  was  suffering.  L.  Schlesinger  (Wien.  Med.  Presse, 
49  and  51,  1873)  also  observed  a  patient  affected  with  hypertrophy  of  the 
left  lower  limb  (which  had  lasted  for  nine  years),  with  normal  electrical 
reactions  and  very  slight  functional  weakness;  this  patient  also  presented 
the  symptoms  of  dementia  paralytica. 

On  account  of  our  ignorance  of  the  true  nature  of  muscular  pseudo- 
hypertrophy, we  are  compelled  to  resort  to  hypotheses.  Fatty  degenera- 
tion of  the  muscles  sometimes  accompanies  certain  central  affections,  such 
as  progressive  muscular  atrophy,  amyotrophic  lateral  sclerosis  (Charcot), 
and  general  paralysis  of  the  insane.  But  even  in  well-marked  cases,  which 
were  examined  by  the  most  competent  histologists,  the  muscular  degen- 
eration was  found  to  be  independent  of  any  appreciable  change  in  the 
cord,  nerve-roots,  or  sympathetic  system. 

We  must  conclude,  therefore,  that  the  muscular  hypertrophy,  which 
complicates  certain  spinal  affections,  plays  merely  a  secondary  and  acces- 
■sory  part.  In  addition  to  the  absence  of  lesions  in  the  nerve-centres, 
there  are  other  important  reasons  for  assigning  a  peripheral  origin  to  the 
■disease  in  question.  In  traumatic  lesions  of  the  nerves  (as  in  the  pre- 
viously quoted  experiments  of  Mantegazza  and  Vulpian,  and  in  the  more 
recent  ones  of  Bizzozero  and  Golgi),  increase  of  the  interstitial  connective 
tissue  and  an  abundant  accumulation  of  adipose  cells  between  the  muscu- 
lar fibres,  advancing  even  to  complete  transformation  of  the  muscles  into 
adipose  tissue,  have  been  observed  in  addition  to  the  atrophy  of  the 
muscular  fibres.  It  is  easier  to  discourse  upon  than  to  demonstrate  the 
relations  which  exist  between  suppression  of  the  trophic  functions  of  the 
nerves  and  the  retrogressive  processes  of  muscular  hypertrophy.  The 
diagnosis  of  muscular  pseudo-hypertrophy  is  based  upon  a  certain  number 
of  important  signs,  viz.  :  the  striking  disproportion  between  the  volume 
of  the  limbs  and  their  motor  functions,  the  peculiar  modifications  in  the 
position  of  the  body  and  in  movements,  the  appearance  of  these  symptoms 


DISEASES    OF    TUE    NERVOUS    SYSTEM.  273 

during  childhood  or  puberty,  the  hereditary  antecedents,  and  the  examina- 
tion of  the  muscles  after  excision  or  harpooning.  For  the  differential  diag- 
nosis from  amyotrophic  lateral  sclerosis  and  spinal  infantile  paralysis,  we 
refer  to  the  details  given  on  page  262,  Vol.  I.,  and  page  4,  Vol.  II. 

The  prognosis  of  fatty  degeneration  of  the  muscles  is  not  absolutely 
unfavorable  during  the  first  period  of  the  disease.  Recovery  may  follow 
the  early  employment  of  electricty,  hydrotherapeutics,  and  massage.  At 
a  more  advanced  stage  these  measures  may  give  rise  to  a  certain  period 
of  arrest  or  to  temporary  improvement  of  the  paralysis,  but  will  not  pre- 
vent the  fatal  issue  of  the  affection.  Hereditary  predisposition  and  severi- 
ty of  the  initial  manifestations  render  the  prognosis  much  more  serious. 

Tonic  remedies  have  not  been  shown  to  produce  any  positive  actic-a 
upon  the  progress  of  fatty  degeneration  of  the  muscles.  Galvanization 
of  the  sympathetic,  which  was  recommended  by  Benedikt,  has  proven 
unsuccessful  in  the  hands  of  Erb,  Roquette,  Guttmann,  and  Berger. 
Duchenne  obtained  recovery  by  the  application  of  local  faradization  con- 
tinued for  months,  and  combined  with  hydrotherapeutics  and  massage. 
In  one  case  I  observed  very  marked  improvement  in  the  motor  power  by 
the  application  of  the  galvanic  current,  for  several  weeks,  to  the  nerves 
of  the  hypertrophied  limbs,  in  addition  to  the  daily  use  of  moist  frictions 
and  cool  baths.  The  action  of  these  various  measures  is  also  furthered  by 
rational  gymnastics  and  by  the  exhilarating  air  of  the  r^ountains. 


9.    TROPHIC   AFFECTIONS    OF   THE    SKIN. 

Danielssen  and  Boeck  (Recueil  d'Observations  sur  les  Maladies  de  la 
Peau,  1856)  first  called  attention  to  the  cutaneous  eruptions  occurring 
along  the  course  of  the  nerves  in  neuralgia.  In  a  patient  who  had  suf- 
fered for  two  months  from  left  intercostal  neuralgia,  complicated  with 
zona,  and  who  died  of  pneumonia,  the  autopsy  revealed  intense  redness 
and  swelling  of  a  large  number  of  the  cutaneous  filaments  of  the  sixth 
left  intercostal  nerve,  with  infiltration  of  the  neurilemma.  Baerensprung 
(Annal.  d.  Charite  zu  Berlin,  lS61-'63)  then  endeavored  to  establish,  from 
a  large  number  of  observations,  that  the  irritation  of  the  trophic  fibres  in 
zona  occurs  at  their  point  of  origin  in  the  intervertebral  ganglia  and  in 
the  Gasserian  ganglion  (in  facial  zona).  Autopsy  showed  injection  a^d 
swelling  of  several  intercostal  nerves  and  of  the  corresponding  interverte- 
bral ganglia.  Under  the  microscope  a  granular  substance  of  a  brownish 
color  (disintegrated  blood-globules)  was  discovered  in  the  sheaths  and  in 
the  interior  of  these  organs,  with  nuclear  proliferation  in  the  connective 
tissue  and  varicose  nerve-fibres  at  some  points. 

Brown-Sequard  (Quart.  Journ.  of  Med.,  May,  1865)  has  observed  cuta- 
neous eruptions  upon  the  arms  in  spinal  meningo-neuritis  of  the  lower 
cervical  region.  Charcot  and  Cotard  (Gaz.  Med.,  1866)  found  intense 
redness  and  enlargement  of  the  ganglia  and  nerve-trunks  within  the  inter- 
vertebral foramina,  in  cancer  of  the  cervical  vertebrae,  which  had  been 
attended  with  zona  along  the  course  of  the  compressed  nerve-plexuses. 
Bahrdt  (Zur.  yEtiol.  des  Herpes  Zoster,  Diss.,  Leipzig,  1866)  and  E. 
Wagner  (Arch.  d.  Heilk.,  1870)  have  seen  tubercular  pachymeningitis 
propagated,  in  vertebral  caries,  to  the  spinal  nerves  and  ganglia  (with 
degeneration  of  the  nerve-cells).  In  one  of  Weidner's  cases  (Ber.  Klin. 
Wschr.,  1870)  the  posterior  root  of  the  thoracic  nerve  contained  connec- 
tive-tissue new  growths,  containing  particles  of  calcareous  matter.  la  a 
Vol.  II.— 18 


274  CLINICAL    TREATISE    ON 

second  case,  reported  by  the  same  author,  the  patient  suffered  from  pain- 
ful herpes  along  the  course  of  the  first  branch  of  the  trigeminus,  with 
relapses  of  neuralgia  and  ophthalmia  of  the  right  eye.  Five  years  later 
the  autopsy  showed  :  hypera?mia  and  cicatricial  retraction  at  the  origin 
of  the  right  fifth  pair  in  the  medulla  oblongata  and  atrophy  of  the  large 
root,  with  exudation  of  a  reddish  fluid  between  the  fibres;  the  nerve-cells 
of  the  Gasserian  ganglion  were  imbedded  in  connective  tissue,  rich  in 
nuclei,  the  interior  of  the  cells  containing  a  finely  granular  and  highly 
pigmented  substance  (traces  of  an  old  inflammation).  Haight  (Wien. 
Akad.  Sitz.-Ber.,  Bd.  57,  1868)  found  the  connective  tissue,  in  the  deeper 
layers  of  the  skin,  softened,  infiltrated  with  cells  (which  were  especially 
abundant  around  the  nerves  of  the  subcutaneous  connective  tissue),  and 
the  nerve-fibres  swollen.  We  may  finally  refer  to  the  important  facts  re- 
ported by  O.  Wyss  (Arch.  d.  Heilk.,  Bd.  XII.,  1871).  In  a  case  of  herpes 
in  the  distribution  of  the  first  branch  of  the  trigeminus,  attended  with 
inflammation  of  the  conjunctiva  and  cornea,  this  author  found  purulent 
inflammation  of  a  portion  of  the  Gasserian  ganglion  and  of  the  nerve, 
extending  even  to  the  small  nerve-filaments  of  the  face,  with  numerous 
pus  globules  between  the  nerve-cells  and  some  extravasations  within  and 
around  the  ganglion. 

The  interpretation  of  these  data,  as  explanatory  of  the  trophic  disturb- 
ances, presents  great  difficulties,  Eulenburg  and  Landois  (loc.  cit.)  regard 
them  as  due  to  vaso-motor  paralysis,  with  increased  pressure  in  the  capil- 
laries, and  the  development  of  vesicles  with  serous  contents.  This  theory 
is  far  from  being  satisfactory,  since  very  marked  paralysis  of  the  vascular 
nerves,  from  division  of  the  sympathetic,  is  unaccompanied  by  similar 
transudations  into  the  integument.  American  military  surgeons  (Mitchell 
and  others)  and  Charcot,  having  found  that  trophic  disorders  of  the  skin 
appear  especially  after  incomplete  nerve  lesions,  regard  them  as  due  to 
inflammatory  irritation  of  the  nerves.  The  latter  author  calls  attention 
to  Paget's  case  of  fracture  of  the  lower  end  of  the  radius,  with  compres- 
sion of  the  median  nerve  during  the  formation  of  callus,  and  inflammatory 
lesions  in  the  corresponding  fingers.  The  ulcerations  only  disappeared 
after  the  compression  of  the  nerve  had  ceased. 

According  to  Friedreich  (loc.  cit.)  the  trophic  disturbances  are  caused 
by  a  neuritis  which  is  propagated  from  the  irritated  point  even  into  the 
cutaneous  filaments  througli  the  medium  of  the  nerve  branches. 

Although  the  anatomical  data  as  well  as  the  clinical  signs  (fever, 
hyperassthesia,  then  cutaneous  anjEsthesia)  favor  the  theory  of  the  inflam- 
matory origin  of  the  trophic  disorders  in  question,  there  are  many  other 
considerations  which  prevent  us  from  always  attributing  them  to  a  neuri- 
tis or  to  an  inflammation  of  the  ganglia.  Perfectly  well-marked  neuritis 
may  develop  without  any  trophic  disturbances,  while,  on  the  other  hand, 
herpetic  eruptions  make  their  appearance  without  any  symptoms  of  irri- 
tation in  the  nerves,  especially  in  young  subjects.  In  cases  of  this  nature, 
in  addition  to  the  very  frequent  propagation  of  inflammation  to  the  skin, 
we  must  admit  an  irritation  of  the  trophic  nerves,  which  will  also  serve  to 
explain  other  alterations  in  the  tissues,  such  as  changes  in  the  hairs  and 
pigmentary  hyperplasias  and  anomalies.  Further  anatomical  and  experi- 
mental investigations  are  necessary  in  order  to  clear  up  these  questions. 

Herpes  zona  of  the  face  usually  appears  upon  one  side,  although  dou- 
ble zona  has  been  observed  by  Hebra,  Moers  (along  the  course  of  all  the 
branches  of  the  trigeminus),  and  Thomas.  Zona  may  also  appear  upon  other 
parts  of  the  body,  and  Esmarch  (Schmidt's  Jahrb.,  Bd.  95)  has  seen  a  case 


DISEASES    OP   THE    NERVOUS    SYSTEM.  275 

extending'  over  the  entire  posterior  surface  of  the  left  leg,  from  the 
buttock  to  the  foot.  The  anatomical  examination  showed  the  presence 
of  neuritis  of  the  sciatic  nerve.  Zona  is  accompanied  by  fever,  and  Trous- 
seau and  M'Crea  (Brit.  Med.  Journ.,  647,  1873)  have  observed  hyperses- 
thesia  and,  later,  anreraia  and  anaesthesia  of  the  skin.  In  addition  to 
zona,  other  trophic  changes  may  occur  in  the  skin,  such  as  erythema, 
erysipelatous  inflammation  of  the  face  (in  prosopalgia,  Anstie),  urticaria, 
and  buUfe  of  pemphigus.  We  have  previously  mentioned  the  hypertro- 
phy of  the  skin  and  the  peculiar  shining  appearance  (glossy  skin)  which 
follow  in  the  wake  of  traumatic  lesions  of  the  nerves.  The  acute  eschars 
(acute  decubitus)  of  cerebral  and  spinal  diseases  have  been  discussed  in 
various  preceding  chapters. 

From  an  etiological  point  of  view,  we  may  add  that  cutaneous  trophic 
disturbances  are  generally  observed  after  traumatic  nerve-lesions,  espe- 
cially when  the  latter  are  incomplete,  and  remain  absent  after  complete 
division  of  the  nerves.  Herpetic  eruptions  also  appear  in  neuralgias, 
febrile  diseases,  intermittent  fever,  and  true  neuritis.  These  exanthe- 
mata are  rarer  in  diseases  of  the  cord,  although  zona  may  be  present  in 
cerebro-spinal  meningitis,  in  cancer,  contusions  and  fractures  of  the  verte- 
bral column,  and  in  acute  and  chronic  myelitis.  I  have  also  seen,  as  I 
have  previously  stated,  herpes  vesicles  along  the  course  of  the  radial 
nerve  in  progressive  muscular  atrophy. 


10.    TROPHIC    AFFECTIONS    OP    THE    BONES    AND    JOINTS. 

Schiff  first  demonstrated  experimentally  the  influence  of  the  nerves 
upon  trophic  changes  in  the  bones.  Division  of  the  nerves  of  the  limbs 
in  mammalia  and  destruction  of  the  lumbar  cord  produce  dilatation  of 
the  blood-vessels,  not  only  in  the  soft  parts  and  muscles,  but  also  in  the 
periosteum  and  bones.  In  an  adult  animal  the  limb  remains  paralyzed 
and  the  diameter  of  the  bones  diminishes  considerably.  The  surfaces  and 
apophyses  are  rounded,  the  medullary  cavities  are  enlarged,  the  perios- 
teum thickened,  and  the  proportion  of  calcareous  matter  diminished. 
Young  animals  develop  poorly,  and  present  hypertrophy  of  the  bones  in 
the  first  few  weeks  after  section  of  the  nerves.  Even  in  adult  animals, 
section  of  the  inferior  dental  nerve  has  produced,  at  the  end  of  several 
weeks,  hypertrophy  of  the  corresponding  half  of  the  jaw.  Schiff  ex- 
plains this  fact  by  the  remark  that  the  preservation  of  the  movements  of 
the  jaw  prevents  atrophy,  while  the  persistence  of  the  vascular  dilatation 
gives  rise  to  hypertrophy. 

Within  the  domain  of  pathology  there  are  numerous  examples  of 
osseous  and  articular  lesions  developing  under  the  influence  of  the  ner- 
vous system.  In  spinal  infantile  paralysis  there  is  atrophy  of  the  bones, 
narrowing  of  the  vessels,  diminution  of  temperature,  and  a  livid  dis- 
coloration of  the  skin.  Virchow  (Gesam.  Abh.,  1858)  has  described  a  case 
of  progressive  paralysis  and  atrophy  of  the  bones  after  typhoid  fever.  The 
autopsy  revealed  a  chronic  myelomeningitis  and  hydrorachis  of  the  cer- 
vical region.  Chambers'  observation  (Med.  Chir.  Trans.,  Vol.  XXXVIL, 
1854)  of  very  marked  muscular  atrophy,  complicated  with  osteomalacia, 
must  undoubtedly  be  classed  among  trophic  disorders  of  central  origin. 
In  Le  Gendre's  and  Friedreich's  case  the  progressive  muscular  atrophy 
presented  the  extremely  rare  complication  of  concentric  osseous  atrophy, 
the  latter  extending  to  the  iliac  bones,  the  ribs,  and  to  the  epiphyseal  car- 


276  CLINICAL    TREATISE    ON" 

tilages.  We  have  referred,  in  a  preceding  chapter,  to  the  osseous  atrophy 
and  other  characteristic  disturbances  of  nutrition  which  occur  in  unilat- 
eral atrophy  of  the  face.  The  periostitis,  and  hypei'trophy  of  the  bones 
and  articulations  observed  after  traumatic  nerve-lesions,  whether  experi- 
mental or  accidental,  have  been  mentioned  on  pages  169-174.  Profound 
changes  in  the  bones  have  also  been  noticed  in  surgical  division  of  the 
large  nerve-trunks  in  man.  In  a  case  reported  by  Romberg  (excision  of 
a  portion  of  the  sciatic  nerve  for  a  neuroma,  by  Dieffenbach)  motor  and 
sensory  paralysis  at  first  occurred  in  the  right  leg.  At  a  later  period 
ulcerations  developed  upon  the  toe  and  outer  surface  of  the  foot,  pieces 
of  necrosed  bone  escaped,  the  skin  desquamated,  the  nails  exfoliated,  and 
the  temperature  of  the  paralyzed  leg  was  considerably  increased. 

Charcot,  Fournier,  and  others  have  observed  arthropathies  and  en- 
largement of  the  metacarpo- phalangeal  articulations  and  of  the  extensor 
tendons  of  the  fingers  in  cerebral  apoplexy.  The  same  class  of  phenomena 
includes  the  forms  of  spinal  arthropathy  recently  described  by  Charcot 
(loc.  cit.).  According  to  Ball,  eleven  analogous  cases  have  been  hitherto 
observed  in  progressive  locomotor  ataxia.  In  these  cases  an  enlargement, 
which  almost  always  occupies  one  of  the  large  joints,  develops  without 
any  external  cause  during  the  period  of  shooting-pains  and  the  initial 
motor  disturbances.  Hydrarthrosis  of  the  knee  occurred  in  Ball's  case, 
and  an  explorative  puncture  showed  the  presence  of  a  serous  fluid  con- 
taining blood-globules.  Revulsive  measures  and  galvanization  [loco 
dolenti  and  upon  the  dorsal  spine)  proved  inefPectual.  In  a  patient  who 
presented  an  enlargement  of  the  shoulder  with  hydrarthrosis  and  creaking 
during  movements,  and  who  died  of  choleraic  diarrhoea,  the  autopsy 
showed:  roughness  and  erosions  upon  the  head  of  the  humerus,  which 
presented  no  trace  of  cartilage,  resorption  of  a  portion  of  the  osseous  sub- 
stance, formation  of  osteophytes;  the  surface  of  the  glenoid  cavity  was 
also  destitute  of  cartilage,  and  the  joint  was  filled  with  a  yellowish  fluid, 
but  without  any  signs  of  inflammation.  The  synovial  capsule  was  merely 
thickened  and  contained  a  deposit  of  some  osseous  lamella?.  The  spinal 
cord  presented  gray  degeneration  of  the  posterior  columns  and  atrophy 
of  the  posterior  roots. 

The  differential  diagnosis  of  these  joint  affections  was  discussed  upon 
page  251,  Vol.  I.,  and  we  then  stated  that  Charcot  and  hispupils  regarded 
atrophy  of  the  cells  of  the  anterior  gray  columns  as  their  anatomical  cause. 
In  the  only  case  in  which  this  lesion  was  absent,  the  spinal  ganglia  were 
very  much  swollen  and  otherwise  changed.  As  the  limbs  which  are  the 
seat  of  these  arthropathies  often  present  muscular  atrophy,  and  as  pro- 
gressive muscular  atrophy  is  sometimes  complicated  with  similar  arthro- 
pathies (Remak,  Patruban,  and  myself),  we  must  conclude  that  the  trophic 
centres  of  the  articulations  are  in  close  proximity  to  those  of  the  muscles 
in  the  cells  of  the  anterior  horns.  ^Ve  may  state,  in  conclusion,  that 
Brown-Sequardhas  seen  arthritis  of  the  knee  develop  upon  the  correspond- 
ing side  after  unilateral  incision  of  the  lumbar  cord. 

The  thickening  of  the  articular  extremities  in  certain  forms  of  arthritis 
has  been  attributed  by  Remak  to  an  affection  of  the  sympathetic  gangha. 
In  such  cases  galvanization  of  the  sympathetic  in  the  neck  will  cause 
diminution  of  the  articular  enlargement  and  of  the  pains,  while  local 
treatment  is  useless.  The  thickening  of  the  heads  of  the  metacarpal 
bones  in  progressive  muscular  atroph}^  was  first  noticed  by  Remak,  and  I 
have  also  met  with  two  examples.  In  another  case  I  observed  a  very 
similar  deformity  of  the  hand  in  a  painter  who  was  suffering  from  lead 


DISEASES    OF    THE    NERVOUS    SYSTEM.  277 

palsy.  Hysterical  arthritis  (Brodie),  with  hyperesthesia,  swelling,  and 
tiedema,  is  regarded  by  Cohen  (Nevroses  vaso-motrices,  Arch.  Gen., 
18C3)  as  a  vaso-motor  hypera'mia  of  the  articulations. 

Inflammations  of  the  nerves,  after  central  or  peripheral  affections,  are 
sometimes  accompanied  by  enlargement,  redness,  and  tenderness  of  the 
joints.  In  lead  paralysis  Gubler  and  Nicaise  have  observed  circumscribed 
swellings  of  the  extensor  tendons,  which  attained  the  size  of  hazel-nuts 
and  were  painful  during  movement.  The  influence  of  nerve  lesions  upon 
these  nutritive  disorders  is  rendered  probable  by  the  appearance  of  simi- 
lar phenomena  in  apoplectic  and  traumatic  paralyses,  in  which  the  articu- 
lations of  the  hand  and  fingers  are  very  frequently  involved. 

This  is  the  actual  condition  of  our  knowledge  concerning  vaso-motor 
neuroses.  They  form  the  first  stones  of  an  edifice  which  future  discov- 
eries must  finish  and  consolidate. 


INDEX. 


INDEX. 


Abdominal  sympathetic,  neuroses  of, 

2G5 
Acoustic  ansstliesia,  191 

hyperffisthesia,  189 

nerve,  neuroses  of,  189 
Acute  epilepsy,  79 
Addison's  disease,  268 

pathological  anatomy,  268 

clinical  history,  269 

diagnosis,  269 

prognosis  and  treatment,  270 
Ageusia,  193 
Amaurosis,  188 

saturnine,  139 
Amblyopia,  188 
Ansemic  paralysis,  151 
Angina  pectoris,  219 

vaso -motor,  264 
Anosmia,  187 
Anterior  scleroses,  1 
Anuria,  hystei'ical,  37 
Arm,  spasms  of,  229 

paralyses  of,  229 
Arsenical  poisoning,  chronic,  143 
Artisan's  neurosis,  126 
Aspermatism,  1.'59 
Atrophy  of  nerves,  176 

Basedow's  Disease,  257 

Bones  and  joints,  trophic  affections  of,  375 

Boulimia,  220 

Brachial  plexus,  paralysis  of,  230 

Brodie's  joint,  29 

Cardialgia,  220 
Catalepsy,  55 

symptomatology,  56 

etiology,  58 

nature,  59 

diagnosis  and  prognosis,  60 

treatment,  61 


Cervico-brachial  neuralgia,  227 
Cervico-occipital  neuralgia,  234 
Chorea  Anglorum,  117 

electrical,  123 
Chorea  magna,  113 

symptomatology,  113 

etiology,  115 

diagnosis  and  prognosis,  115 

treatment,  116 
Chorea  minor,  117 
.    pathological  anatomy,  117 

symptomatology,  119 

etiology,  120 

nature  of  chorea,  122 

diagnosis  and  prognosis,  133 

treatment,  123 
Chorea,  tetanic,  123 
Choreomania,  115 
Coccygodynia,  249 
Collum  obstipum,  232 
Convulsive  tic,  197 
Cranial  nerves,  diseases  of,  187 
Craniotabes,  85 
Crural  neuralgia,  338 

Deaf-mutism,  191 
Degeneration  reaction,  171 
Diaphragm,  paralysis  of,  327 

tetanus  of,  226 
Diphtheritic  paralysis,  148 
Diplegic  contractions,  16 
Dorso-intercostal  neuralgia,  235 

Eclampsia,  79 
Eclampsia,  lead,  86 

Eclampsia    of    pregnant     and     puerperal 
women,  79 

of  children,  84 

toxic,  86 
Eraprosthotonos,  90 


282 


INDEX. 


Enteralgfa,  265 
Epilepsy,  63 

pathological  anatomy,  63 

symptomatology,  66 

etiology,  68 

nature,  70 

diagnosis,  73 

prognosis,  74 

treatment,  75 
Epilepsy,  acute,  79 
Exophthalmic  goitre,  257 

symptomatology,  257 

pathological  anatomy,  258 

etiology,  259 

nature  of,  260 

treatment,  261 

Face,  unilateral  atrophy  of,  256 
Facial  muscles,  spasms  of,  197 
Facial  paralysis,  198 

Facial  paralysis,  from  diseases  at  base  of 
brain,  199 

from   suppuration  in  auditory  appa- 
ratus, 199 

rheumatic,  199 

traumatic,  203 

syphilitic,  208 

diphtheritic,  204 
Facial  paralysis,  double,  205 
Febrile  nervous  disorders,  145 

Gastkodtnia,  220 
Goitre,  exophthalmic,  257 
Griffe  de  la  main,  14 

Hemian^-sthesia,  80 
Hemiatrophy,  facial,  256 
Hemicrania,  254 
Herpes  zoster,  283 
Hiccough,  225 
Hydrophobia,  100 

symptomatology,  100 

pathological  anatomy,  102 

nature,  103 

diagnosis  and  prognosis,  104 

treatment,  104 
Hypergeusia,  192 
Hyperosmia,  187 
Hypoglossal  nerve,  spasms  of,  206 

paralysis  of,  206 
Hysteralgia,  238 


Hysteria,  29 

symptomatology,  29 

pathological  anatomy,  40 

etiology,  41 

nature  of,  44 

diagnosis,  47 

prognosis,  48 

treatment,  49 
Hysterical  trance,  89 
Hysterical  somnambulism,  88 
Hystero-epilepsy,  35 

Impotence,  157 
Irritable  breast,  236 
Ischsemic  paralysis,  151 
Ischuria,  hysterical,  87 

Lead  arthralgia,  189 
Lead  encephalopathy,  188 
Lead  paralysis,  140 

symptomatology,  140 

pathological  anatomy,  141 

treatment,  142 
Lepra  anassthetica,  179 
Lower  limbs,  paralysis  of,  248 

spasms  of,  245 
Lumbo-abdominal  neuralgia,  237 
Lysses,  101 

Mastodtnia,  236 

Mercurial  nervous  affections,  143 

Migraine,  254 

sympathico-tonic,  254 

sympathico  paralytic,  255 
Muscular  pseudo-hypertrophy,  270 

etiology,  270 

clinical  history,  270 

pathological  anatomy,  271 

diagnosis,  272 

prognosis  and  treatment,  273 
Muscular  rheumatism,  166 
Muscular  sense,  32 

Nerves,  atrophy  of,  176 

inflammation  of,  178 

neoplasms  of,  177 

rheumatic  lesions  of,  163 

traumatic  lesions  of,  168 

regeneration  of,  168 
Nervous  disorders,  febrile,  145 

post-febrile,  145 
Neuralgia,  180 

symptomatology,  181 


INDEX. 


283 


Neuralgia — etiology,  182 

diagnosis,  183 

prognosis,  184 

treatment,  185 
Neuralgia,  abdominal,  230 

articular,  350 

cardiac,  219 

cervico-brachial,  227 

cervico-occipital,  224 

coeliac,  266 

crural,  238 

dorso-intercostal,  235 

hysterical,  33 

intercostal,  235 

lumbo-abdominal,  237 

mammary,  236 

obturator,  238 

of  the  testis,  238 

phrenic,  225 

Bciatic,  240 

trigeminal,  207 

traumatic,  170 

uterine,  288 
Neurasthenia,  26 

symptomatology,  26 

etiology,  27 

diagnosis,  28 

treatment,  28 
Neurectomy,  212 
Neuritis,  178 
Neuromata,  177 
Neuroma,  cicatricial,  177 
Neurotomy,  212 
Neuio-retinitis,  saturnine,  139 

Ocular  muscles,  paralysis  of,  194 
Olfactory  nerve,  diseases  of,  187 
Oliguria,  hysterical,  37 
Opisthotonos,  90 
Ophthalmia,  trophic,  215 
Optic  nerve,  diseases  of,  188 

hypertesthesia  of,  188 
Ortho  tonos,  90 

Paralysis  agitans,  109 

anatomical  lesions,  109 

symptomatology,  110 

etiology,  111 

diagnosis,  112 

treatment,  112 
Paralysis,  anaemic,  151 

diphtheritic,  148 


Paralysis — facial,  198 

infantile,  2 

ischsemic,  151 

reflex,  153 

temporary,  of  children,  8 

traumatic,  170 

trigeminal,  213 
Peripheral  nerves,  diseases  of,  176 
Peripheral  paralysis,  general  characteris- 
tics of,  161 
Phrenic,  nervous  disorders  of,  235 
Pleurosthotonos,  90 
Pneumogastric  nerve,  diseases  of,  216 
Poliomyelitis  anterior  acuta,  9 
Pollutions,  155 

in  females,  44 
Polydypsia,  220 
Polyphagia,  221 

Post-febrile  nervous  disorders,  145 
Progressive  muscular  atrophy,  11 

pathological  anatomy,  11 

etiology,  13 

symptomatology,  14 

theory,  17 

diagnosis  and  prognosis,  19 

treatment,  21 
Prosopalgia,  2!i7 
Psellismus  saturninus,  140 
Pseudo-neuromata,  177_ 
Puncta  dolorosa,  181 

Recurrent  sensibility,  173 

Reflex  paralysis,  152 

Reflex  traumatic  paralysis,  174 

Salaam  convulsion,  223 
Saltatory  spasms,  115 
Saturnine  affections,  137 
Sciatica,  240 

pathological  anatomy,  240 

symptomatology,  240, 

etiology,  242 

diagnosis,  243 

prognosis,  243 

treatment,  243 
Seminal  losses,  155 
Sexual  neuroses,  155 
Skin,  trophic  affections  of,  273 
Spinal  accessory,  diseases  of,  231 
Spinal  irritation,  hyperaesthetic  form  of,  23 

symptomatology,  22 

etiology,  24 


284 


INDEX. 


Spinal  irritation — diagnosis,  24 

treatment,  25 
Spinal  paralysis,  acute,  of  adults,  9 
Spinal  paralysis,  infantile,  2 

pathological  anatomy,  2 

etiology,  3 

symptomatology,  4 

diagnosis  and  prognosis,  6 

treatment,  8 
Spinal  paralysis,  subacute  anterior,  10 
Status  epilepticus,  68 
Stridulous  laryngitis,  217 
Stuttering,  131 

symptomatology,  131 

etiology,  132 

diagnosis  and  prognosis,  134 

treatment,  134 
Stuttering,  gutturo-tetanic,  132 

labio-choreic,  132 

spinal,  133 
Sympathetic    system,    traumatic    lesions 
of,  261 

rheumatic  lesions  of,  263 

Taste,  anaesthesia  of,  192 
hyperEesthesia  of,  192 


Tephromyelitis,  9 
Tetanus,  89 

pathological  anatomy,  89 

symptomatology,  90 

etiology,  92 

nature,  95 

diagnosis  and  prognosis,  96 

treatment,  97 
Tetanus  neonatorum,  92 
Tetany,  92 
Tic-douloureux,  207 
Torticollis,  222 
Trachelismus,  71 
Tremor,  107 
Trismus,  89 
Toxic  neuroses,  137 
Traumatic  paralysis,  reflex,  174 
Trigeminus,  neuralgia  of,  207 

spasms  of,  213 
Tussis  convulsiva,  217 

Writer's  cramp,  126 
symptomatology,  126 
etiology,  127 

diagnosis  and  prognosis,  128 
treatment,  129 


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